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1 STRESS AND PATIENT-CENTERED CULTUR ALLY SENSITIVE HEALTH CARE AS FACTORS IN NUTRITION BEHAVIORS AMONG AFRICAN AMERICAN WOMEN By JESSICA DOROTHY JONES A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2007
2 2007 Jessica Dorothy Jones
3 To my parents, for all the things they do
4 ACKNOWLEDGMENTS My appreciation belongs to m y parents, Edward and Fran Jones, and my brother, Eddie. I thank them for their unconditional support and encouragement. Without their love I know my achievements could not have gone this far. I al so thank Cruz Bueno a nd Christian Nielsen for their continuous encouragement during this le ngthy thesis writing process and for simply understanding me. Finally, my deep est gratitude belongs to Dr. Carolyn Tucker. Her unwavering support has been crucial in my progress througho ut my thesis writing process and graduate training. I also thank her for her mentorship a nd encouragement which have been invaluable.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 LIST OF FIGURES.........................................................................................................................8 ABSTRACT.....................................................................................................................................9 CHAP TER 1 INTRODUCTION..................................................................................................................11 Hypertension and Related Health Conditions......................................................................... 11 Nutrition Behaviors to Treat and Prevent H ypertension and Related Health Conditions ...... 12 Stress and Nutrition Behaviors............................................................................................... 15 Patient-Centered Culturally Sensitive H ealth Care and Nutrition Behaviors .........................16 2 LITERATURE REVIEW.......................................................................................................21 Hypertension and Related Health Conditions......................................................................... 21 Hypertension and Related Health Cond itions Am ong African American Women................ 23 Barriers to Healthy Nutriti on Behaviors to T reat Hypertension and Related Health Conditions...........................................................................................................................24 Barriers to Healthy Nutr ition Behaviors Am ong African American Women........................ 26 Stress.......................................................................................................................................28 Patient-Centered Culturally Sensitive Health Care ................................................................35 Summary.................................................................................................................................40 Hypotheses and Research Question........................................................................................ 41 3 METHODS.............................................................................................................................42 Participants.............................................................................................................................42 Measures.................................................................................................................................44 Demographic Data Questionnaire...................................................................................44 Medical Data Sheet..........................................................................................................44 Health Promoting Lifestyle Profile................................................................................. 44 Marlowe-Crowne Social Desirability Scale ....................................................................45 Strain Questionnaire........................................................................................................45 Tucker Culturally Sensitive Health Care Inventory African Am erican Patient Form.............................................................................................................................46 Procedure................................................................................................................................47
6 4 RESULTS...............................................................................................................................51 Descriptive Data for the Major Variables of Interest and Social Desirability ........................ 51 Correlations between Major Variables of Interest and Social Desirability ............................ 52 Results from the Analyses to Test Hypotheses 1 and 2 .......................................................... 52 Results from the Analyses to Test the Research Question..................................................... 54 5 DISCUSSION.........................................................................................................................61 Summary and Interpretations of the Findings........................................................................ 62 Limitations of the Present Study............................................................................................. 66 Clinical Implications and Future Directions........................................................................... 68 Conclusion..............................................................................................................................69 APPENDIX A DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ)......................................................... 71 B MEDICAL DATA QUESTIONNAIRE (MDS).................................................................... 73 C HEALTH PROMOTING LIFESTYLE PROFILE II (HPLP-II)........................................75 D MARLOW-CROWNE SOCIAL DESIRABILI TY SCALE (MCSDS)................................. 78 E STRAIN QUESTIONNAIRE (SQ)........................................................................................ 79 F TUCKER CULTURALLY SENSITIVE HEALTH C ARE INVENTORY-AFRICAN AMERICAN PATIENT FORM (T-CUSCHI-AA)................................................................ 81 G STUDY PARTICIPATION INVITATION LETTER............................................................ 86 H INFORMED CONSENT FORM............................................................................................ 88 I STUDY QUESTIONNAIRE PACKET COVER LETTER................................................... 91 LIST OF REFERENCES...............................................................................................................93 BIOGRAPHICAL SKETCH.......................................................................................................102
7 LIST OF TABLES Table page 3-1 Descriptive statistics for the dem ogr aphic variables in the present study......................... 50 4-1 Descriptive statistics for the m ajor variab les of interest and social desirability................ 57 4-2 Intercorrelations between and am ong the ma jor variables of interest and social desirability..........................................................................................................................58 4-3 Summ ary of the multiple regression analysis for the stress variables predicting nutrition behaviors............................................................................................................ .59 4-4 Summ ary of the multiple regression analysis for the patient-centered cultural sensitivity in health care variab les predicting nutrition behaviors.....................................59 4-5 Hierarchical m ultiple regression models with behavioral stress, cognitive stress, and nutrition behaviors as criterion variables and age, educational attainment level (average and high), and their in teraction terms as predictors............................................ 60
8 LIST OF FIGURES Figure page 1-1 Patient-centered culturally se nsitive health care model ..................................................... 20 4-1 Age Educational Attainm ent Level (EAL) predicting behavioral stress........................ 61
9 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Masters of Science STRESS AND PATIENT-CENTERED CULTUR ALLY SENSITIVE HEALTH CARE AS FACTORS IN NUTRITION BEHAVIORS AMONG AFRICAN AMERICAN WOMEN By Jessica Dorothy Jones December 2007 Chair: Carolyn M. Tucker Major: Psychology The major purpose of the current study is to examine self-reported levels of stress (physical stress, behavioral stress, and cognitive stress) and patient-centered cultural sensitivity in health care experienced (health care provider behaviors/atti tudes, office staff behaviors/attitudes, and health care center character istics and policies) as factors in self-reported nutrition behaviors among low-in come African American women patients. The current study also examined the associations of participants age and level of educational attainment with their self-reported levels of (a) stress, (b) patient -centered cultural sensitivity in health care experienced, and (c) nutrition behaviors. Partic ipants in this study included 80 low-income African American women patients who ranged in age from 19 to 85 with a mean age of 51.34. A multiple regression analysis revealed that self -reported levels of stress were significant predictors of the self-reported level of nut rition behaviors among the low-income African American women patients in this study. Higher self -reported levels of be havioral and cognitive stress were associated with lower self-reporte d level of nutrition beha viors, as hypothesized. Higher self-reported level of physical stress was associated with higher self-reported level of nutrition behaviors. Results also revealed that the participating women patients self-reported
10 levels of patient-centered cultural sensitivity in health care experienced were not significant predictors of self-reported level of nutrition behaviors. Separate hierarchical multiple regression analyses were performed to determine if age and educational attainment le vel of the particip ating African American patients were significantly associated with their self-reported levels of stress, patient-centered cultural sensitivity in the health care experienced, and nutrition behaviors. Th ese regression analyses revealed that the behavioral stress scores of the women with lower education attainment levels decreased significantly as age increased, whereas th e behavioral stress scores of the women with higher educational attainment levels increased significantly as age increased. It was also found that age was a positive predictor of cognitive stress scores and that both age and educational attainment level were positive predictors of nutrition behavior scores An important implication of the findings from the present study is that stress management training may enhance the effectiveness of health care regimens to increase health promoting behaviors among low-income African American women diagnosed with or at risk for hypertension and/or related health conditions. Such stress management training may be particularly important for African American wo men who experience high stress in association with age and educational attainment level. The present research findings also provide support for future similar research with larger and divers e samples of low-income African American women patients. If this future research supports the present research findings, support will be provided for using stress assessments and interventions ba sed on these assessments in health care to modify or prevent hypertension and related health conditions.
11 CHAPTER 1 INTRODUCTION Hypertension and Related Health Conditions According to the National Health and Nutr ition Exam ination Survey (NHNES) from 1998 to 2000 (Hajjar & Kotchen, 2003) and the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (Chobanian, Bakris, Black et al., 2003; National Institute s of Health [NIH], 2003), hypertension is an increasingly important public he alth issue. Hypertension is in dicated when an individuals systolic blood pressure reading is greater than or equal to 140 mmHg and/or diastolic blood pressure reading is greater than or equal to 90 mmHg (Chobanian et al ., 2003). Individuals with hypertension face increased risks of having a heart a ttack, kidney disease, stroke or the presence of other life threatening cardiovas cular-related diseases. Hypertension affects one of every three Americans. It is also noteworthy that more than 50% of those with hypertension are over the age of 65 (Anderson, 1991; Fields, Bu rt, Cutler, et al., 2004). Hypertension is a common comorbidity of diab etes, high blood cholesterol, and coronary heart disease and is also considered a controlled risk factor for these re lated health conditions (Center for Disease Control and Prevention [C DC], 2005b; Hypertension in Diabetes, 2002). Improvement in blood pressure control can signi ficantly reduce the burden and prevalence of hypertension and these related health conditions. Unfortunately, racial differences in blood pressure control exist and as a result hyperten sion and related health conditions remain a common problem among certain ethnic groups (Bosworth, Dudley, Olsen et al., 2006). Specifically, uncontrolled blood pressure has been exhibited more by African Americans than any other ethnic group (Boswort h et al., 2006; CDC, 2005b). African Americans are 20% more likely than non-Hispanic Whites to experience hypertension-related deat hs as a result of
12 uncontrolled blood pressure (Anderson, 1991). When compared with non-Hispanic Whites, African Americans develop hyperten sion and related health conditions at an earlier age and are more likely to have organ damage as a result of delayed diagnosis and treatment related to blood pressure control (Anderson, 1991; Brown, 2004; Hick s, Fairchild, Horng et al., 2004). Thus, the disparity in the onset and negative impact of hypertension and related health conditions may be associated with lower levels of education a nd less annual incomes among African Americans as compared to non-Hispanic Whites (Hypertension in America, 2005). Among all ethnic and gender groups, African Amer ican women have the highest rates of morbidity and mortality as a result of uncontro lled blood pressure (Ahi jevych & Bernhard, 1994; Johnson, 2005). Results taken from the National Health and Nutrition Examination Survey (NHANES) conducted from 1999 to 2000, from 1988 to 1991, and from 1991 to 1994 suggest that hypertension has increased in prevalence, and this increased prevalence is highest among African American/Black wome n (7.2%) and lowest among non-Hispanic White men (1.0%, Hajjar & Kotchen, 2003). African American wome n also have the highest age-adjusted prevalence of coronary heart disease in the U. S., and furthermore, African American women living in the southeastern U.S. have the greatest prevalence of hypertension and cardiovascular disease mortality among all U.S. women (American Heart Association, 2004). Hence, the focus of the current study will be on lo w-income African American wome n diagnosed with or at risk for hypertension and/or related heal th conditions (diabetes, high blood cholesterol, and coronary heart disease). Nutrition Behaviors to Treat and Prevent Hy pertension and Related Health Conditions According to W ard, Morisky, Lees, and Fong (2000), insufficient blood pressure control and the onset of hypertension and related health conditions (diabetes, high blood cholesterol, and coronary heart disease) are the result of non-compliance to reco mmended lifestyle modifications
13 (health promoting nutrition and exercise behavior s) and the accumulation of risk factors (alcohol use, smoking, and eating high-sodium and high -fat diets). In additi on to pharmacological treatment, compliance to recommended lifestyle modifications such as health promoting nutrition behaviors and exercise behaviors help constitute the typical treatment regimen to control blood pressure. Only 30% to 50% of patients with hy pertension and related health conditions adhere to pharmacological treatments a nd an even smaller perc entage of patients are compliant with lifestyle modifications (Ward et al., 2000). Compliance to lifestyle modifications refers to the extent to which a persons behaviors (e.g., nutrition behaviors) coincide with the health behaviors recommended by his/her health care provider (Eraker, Kirscht, & Becker, 1984). Researchers from the Dietary Approaches to Stop Hypertension (DASH) Sodium Feeding Study have documented that health promoting nutri tion behaviors such as limiting the intake of salt and alcohol consumption and eating a diet that emphasizes vege tables, fruits, and low-fat or fat-free dairy products can reduce sy stolic and diastolic blood pre ssure readings of hypertensives by 11.4 and 5.5 mmHg, respectively (Appel, 2003). Even more noteworthy, researchers found that blood pressure readings of African Americans who participated in the DASH Sodium Feeding Study were significantly reduced to an even greater extent when compared to blood pressure readings of non-Hispanic White partic ipants (Svetsky, Simons-Morton, Vollmer et al., 1999; Whelton, He, Appel et al., 2002). Thus, lifesty le modifications such as health promoting nutrition behaviors can serve as initial treatment before the start of drug therapy and as an adjunct to medication in persons already on drug therapy (Appel, 2003, p. S99). More importantly, research shows that modifications in nutrition behaviors among African Americans
14 can significantly increa se blood pressure control, thus re ducing the prevalence of hypertension and related health conditions among this group. Despite the findings of thes e studies, a large proporti on of low-income African Americans maintain higher rates of uncontro lled blood pressure. One reason for uncontrolled blood pressure among this group is the increase in hea lth care related costs. Many low-income patients diagnosed with or at risk for hypertension and related health conditions cannot afford to pay for unnecessarily increased health care re lated costs, which all Americans must pay. National initiatives such as those set fort h by Healthy People 2010 (2000) and JNC 7 (2003) include a call for health and hea lth care researchers and provider s to aid in finding cost-effective ways to reduce blood pressure in special populations (e.g., the poor and ethnic minorities). More importantly, researchers also recognize that the adoption of health promoting behaviors may be harder for certain groups in the general populatio n than others,, thus potential barriers in the adoption and maintenance of these types of behaviors need to be examined for low-income and African American individuals. A major focus of the present study is to exam ine psychosocial factors (stress and patientcentered culturally sensitive health care) that influence the adoption of health promoting behaviors (i.e., nutrition behaviors) that constitute a part of recommended lifestyle modifications among low-income African American women diagnos ed with or at risk for hypertension and/or related health conditions (diabetes, high blood ch olesterol, and coronary heart disease). This study is of particular importance because African Americans, particular ly African American women, are overrepresented in the low socioeco nomic group of individuals in the U.S. (Winkleby, Kraemer, Ahn, & Varady, 1998).
15 Stress and Nutrition Behaviors Stress has b een defined as the appraisal of an individual exposed to a noxious environment which threatens to deplete their re sources or endanger their well-being (Lazarus & Folkman, 1984). Researchers suggest that one s own race and socioeconomic status can influence the perception of an environment as psychologically and/or phy siologically stressful (Clark, Anderson, Clark, & Williams, 1999; Lazurus & Folkman, 1984). Because of their ethnicity/race, African Americans are often exposed to both repeated raci sm and discrimination over time in their environments (Thoits, 1991). These negative e xperiences may be appraised by African Americans as stressful, which as a consequence place them at a disproportionately greater risk for physical illnesses such as hype rtension, cardiac disease, obesity, and drug and alcohol abuse than any other ethnic group (Clark et al., 1999; Outlaw, 1993). Furthermore, stress that is derived from soci o-environmental stimuli, such as exposure to racism, may also deter low-inco me African Americans with or at risk for hypertension and related health conditions from adopting recommended lifestyle modifications (e.g., nutrition behaviors that include reducing sodium and fa t intake) that are nece ssary to control blood pressure (Baum, Garofalo, & Yali, 1999; Clar k et al., 1999; Griffin, Fr iend, Eitel, & Lobel, 1993). This contention is supporte d by several research asserti ons. For example, it has been asserted that the inability to adopt and maintain lifestyle modifications such as eating healthy foods may be the result of daily lifestyle stressors associated with being poor (Schoenberg, 1997; Ward et al., 2000). Additionally, it has been asse rted that health care providers may fail to recognize that lifestyle changes for African Americans may be impeded by stressful environmental stimuli, cultural beliefs and practi ces and attitudes associ ated with nutrition and the health care system (Charles, Good, Hanusa, Chang, & Whittle, 2003; Schoenberg, 1997).
16 In a study that examined stress, coping, a nd regimen adherence as determinants of chronic and transient metabolic control of type 1 and type 2 diabetics, Peyrot, McMurry, and Kruger (1999) posit the following: As the level of psychological stress increases, it may be difficult for patients to maintain a demanding regime n while dealing with other pressures in their daily lives (p. 143). Griffin et al (1993) also state that the priority one gives to engaging in lifestyle modifications may shif t during stressful life periods a nd in stressful environments. These statements are further supported by resear chers who emphasize that providers and office staff at health care centers should work to provi de services to low-income and ethnic minority patients in a stress-reducing manner (Cappas, Andres-Hyman, & Davidson, 2005; Wohl, 1989). Little research has specifica lly examined the particular stressors experienced by women of different racial groups, the relationships of thes e stressors to social contexts, and the ways that differences in these experiences may contribute to racial differences in womens health outcomes and behaviors (Schulz et al., 2000). African American women, in particular, often face the stress related to raising children in single-parent households and the strain of being the sole economic provider for their families (Schulz, Israel, W illiams et al., 2000). Research has shown that African American women with hypertension and related health conditions are less likely to engage in health promoting behaviors as a result of stress (Walco tt-McQuigg, 1995; WalcottMcQuigg, 2000). However, there is a paucity of em pirical research on the association of stress with health promoting behaviors, such as nut rition behaviors, among A frican American women. Patient-Centered Culturally Sensitive Health Care and Nutrition Behaviors As the diversity of the U .S. continues to increase and health disparities continue to persist, the medical field is challenged with a ddressing the problem of pr oviding health care that is sensitive to and respectful of patients dive rse cultures (Institute of Medicine, 2002; Smedley, Stith, & Nelson, 2003). Numerous hea lth care organizations are call ing for culturally sensitive
17 health care by culturally competent professionals to improve the effectiveness of health care delivery to all patients (Comm ittee on Quality Health Care in America, 2001; Institute of Medicine, 2002; Minorities in Me dicine, 1998). Yet, there is a l ack of agreement as to what constitutes culturally sensitive health care and th ere is limited research on its link to health promoting behaviors and health outcomes. According to Tucker, Mirsu-Paun, van den Be rg et al. (in press) patient-centered culturally sensitive health care emphasizes displaying patient-desired modifiable provider and staff behaviors and attitudes, implementing health care center policies, and displaying physical health care center characteristics and policies that culturally diverse patients identify as indicators of respect for their culture and that enable these patients to feel comfortable with, trusting of, and respected by their health care providers and office staff. Furthermore, Herman, Tucker, Ferdinand et al. (in press) posited that culturally sensitive health care not only encompasses the meaning of cultural competence but moves beyond this meaning by emphasizing patient centeredness (p. 8). Patient centeredness means that the patients wants, needs, perceptions, and feelings inform the hea lth care delivery process and that the patients feelings of interpersonal contro l and empowerment are fostered. A ccording to Herman et al. (in press) the health care clinic setting is critical in enabling patients, especially low-income African American patients, to feel comfortable (p. 11). Kreps and Thornton (1984) posit that the lack of cultural sensitivity can cause dissatisfaction and stress for both providers and patients which can contribute to poorer health outcomes for patients. Although there has been str ong support for culturally sensitive health care, this care has not been linked to patients health promoting behaviors ( health promoting nutrition behaviors). Examining this link among low-inco me African American women patients diagnosed
18 with or at risk for hypertension and/or related health conditions is particularly important because such women are often the sole primary caregivers in the family and thus must avoid costly and life threatening chronic health conditions that can negativel y impact the lives of their family. Furthermore, women in general are often the mo st responsible for food preparation and most concerned with their familys health a nd nutrition related behaviors (James, 2004). As part of a larger project on patient-cente red culturally sensitive health care, the distinguishing primary objective of the current study was to examine se lf-reported levels of stress (behavioral stress, cognitive stress, a nd physical stress) and patient-centered, cultural sensitivity in health care experienced (provider behaviors/attit udes and office staff behaviors/attitudes and health care center characteri stics and policies) as factors in the level of engagement in health promoting nutrition be haviors among low-income African American women patients with or at risk for hypertension a nd/or related health conditions (diabetes, high blood cholesterol, and coronary artery disease). This study is informed in part by the literaturebased Patient-Centered Culturally Sensitive Hea lth Care Model (Tucker, Herman, Ferdinand et al, in press) that was tested in the larger study. This model asse rts that (a) patient and provider training can promote patient-center ed culturally sensitive health care as indicated by physical environment characteristics of the health care center, provider behaviors/attitudes, and office staff behaviors/attitudes; (b) th is care influences patients per ceived levels of provider cultural sensitivity and interpersonal control, both of which impact patient s level of engagement in a health promoting lifestyle and level of health care satisfaction; (c) the latter influences patients level of treatment adherence; a nd (d) both level of tr eatment adherence and level of engagement in a health promoting lifestyle directly influen ce patients health outcomes/statuses. This model is depicted below in Figure 1-1.
19 Even though stress was not considered in th e model several studies have suggested an association between stress and health promo ting behaviors (Walcott-McQuigg, 1995; WalcottMcQuigg, 2000). Thus, in the current study both self-reported levels of stress (physical, behavioral, and cognitive stre ss) and patient-centered cultura l sensitivity in health care experienced (provider behaviors/at titudes, office staff behaviors/at titudes, and health care center characteristics and policies) were examined as predictors of health promoting nutrition behaviors among low-income African American women patient s diagnosed with or at-risk for hypertension and/or related health conditions (diabetes, high blood cholesterol, and coronary heart disease).
20 Figure 1-1 Patient-centered culturally sensitive health care model Patient-centered Culturally Sensitive Health Care Intervention Program Physical Health Care Environment Provider/Staff Behaviors Patient Behaviors PatientPerceived Cultural Sensitivity PatientPerceived Interpersonal Control Patient Health Promoting Lifestyle Patient Satisfaction Patient Treatment Adherence Patient Health Outcome/Status Variables
21 CHAPTER 2 LITERATURE REVIEW The purpose of this chapter is to review the res earch literature that is relevant to the focus of the present study and underlie its rationa le. Specifically, this chapter will focus on hypertension as well as related health condi tions of hypertension ( diabetes, high blood cholesterol, and coronary heart disease), stress, and patient-cente red culturally sensitive health care. In addition, the literature on the links among stress, patient-centered culturally sensitive health care, and health promoting nutrition be haviors particularly among low-income African American women will be reviewed. Hypertension and Related Health Conditions An estim ated 65 million individuals have hype rtension or high blood pressure, which is considered the most common primary diagnosis in America (Bosworth, Dudley, Olsen et al., 2006; Chobain, Bakris, Black et al ., 2003). Uncontrolled hypertension is a major risk factor for diabetes, high blood cholesterol, and coronary heart disease (Center for Disease Control and Prevention [CDC], 2005b; Diabetes in Hyperten sion, 2002). Hypertension is also a major risk factor for kidney disease, stroke, congestive h eart failure, and renal disease (Bosworth et al., 2006). Between the years of 1988 and 1994 only 23.1% of patients who have been diagnosed with hypertension and who were under treatment had controlled blood pressure. Between 1999 and 2002, blood pressure control rates increase d significantly to 29.4% (National Healthcare Quality Report, 2005). However, this increase is inconsistent with the blood pressure control goal set forth by the U.S. Department of Hea lth and Human Services (DHHS)s Healthy People 2000 Report. Despite this fact, the DHHS (2000) has reestablished the sa me goal for the year 2010 which is to increase the nations blood pressure control rate to 50%.
22 The Seventh Report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of Hi gh Blood Pressure (2003; Qureshi, Suri, Kirmani, & Divani, 2005) provides new clinical guid elines for reducing and managing the prevalence of high blood pressure. Following the release of the prior JN C 6, two changes to the classification of hypertension have been made, and these changes are reported in the JNC 7. Given the similarity of approaches in the treatment and management of individuals w ith stage 2 (BPs ranging from 160 179 mmHg systolic and/or 100 109 mmHg diastolic) and stage 3 (BPs at or greater than 180 mmHg systolic and/or 110 mmHg diastolic) hypertension, these two stages were combined to create the new stage 2 hypertension classification. In addition, a new hypertension classification termed prehypertension was intro duced to identify individuals who are at high risk for developing hypertension. According to Qureshi et al. (2005) a tota l of approximately 11 million women and men have been diagnosed with stage 2 hypertension, and an even higher number (25 million) have been diagnosed with stage 1 hypertension (BPs ranging from 140 159 mmHg systolic and/or 90 99 mmHg diastolic). Based on the new classifications of the JNC 7, an alarmingly number (70 million) of women and men were reported to have been diagnosed with prehypertension (Qureshi et al., 2005). Prehypert ension includes individuals with blood pressure ranging from 120 139 mmHg systolic and/or 80 89 mmHg diastolic The new classification will allow health care providers to recommend early health promoting interventions that emphasize modifications to dietary intake and physical activity toward the goal of preventing and/or reducing the severity of hypertension and re lated health conditions ( diabetes, high blood cholesterol, and coronary heart disease).
23 Between the years of 1988 to 1994 and the ye ars of 1999 to 2000, Quershi et al. (2005) observed a significant increase in the prevalence of prehypert ension among African Americans in an analysis of the National Health and Nutrition Examination Survey (NHNES). Quershi et al. also reported that African Americans had the highest age-adjusted prevalence of stage 1 hypertension (15.5%) and stage 2 hypertension ( 8.1%) when compared to the general population. Charles, Good, Hanusa, Chang and Whittle (2003) contend that African Americans as compared to non-Hispanic Whites are more likely to su ffer from a sequelae of chronic conditions (congestive heart failure, end-st age renal disease, and stroke ) as a result of hypertension. Hypertension and Related Health Co nditions Among African American Women Although African Am erican men and women both experience a significant burden from hypertension and related health conditions, African American women experience higher rates of mortality and morbidity due to these conditions when compared to their male counterparts. According to Hajjar and Kotchen (2003), African American women have th e greatest incidence of hypertension when compared to other gender a nd race/ethnic groups, and among these women, there is a greater prevalence of hypertension among younger women. According to Casper Barnett, Halverson et al. (2000), nine perc ent of heart disease deaths among African American women are a consequence of hypertensive heart disease, whereas among non-Hispanic White women and Asian and Pacific Island women, only three percent of heart disease deaths are a consequence of hyperten sive heart disease. The American Heart Association (2004) also states that African American women have the highest age-adjusted prevalence of coronary heart disease in the U.S. when compared to nonHispanic Whites and other ethnic groups. The prevalence of hypertensi on and cardiovascular disease mortality is also greater among African American women living in the southeastern U.S.
24 when compared to all U.S. wo men. Additionally, cardiovascular disease is ranked the number one cause of death for African American women in the U.S., and these women are four times more likely to die from this disease than their non-Hispanic White counter parts (Appel, Harrell, & Deng, 2002; Walcot-McQuigg, 2000). Rates of acu te ischemic heart disease are also substantially higher in African American women when compared to non-Hispanic White women, while the rates are similar between African American men and non-Hispanic White men (Charles et al., 2003). Moreover, nearly 54% of deaths among African American women are attributed to ischemic heart dis ease (Women Heart Disease, 2006). Barriers to Healthy Nutrition Behaviors to Treat Hypertension and Related Health Conditions Despite the public awareness of the issues re garding the risks asso ciated with high blood pressure, fewer than 25 percent of Am ericans c onsume five or more servings of fruits and vegetables daily and an even higher percentage (34%) engage in unhealthy practices such as smoking and alcohol consumption (NIH, 2003). In a study conducted by Baumann, Chang and Hoebeke (2002), risk factors for cardiovascular disease were found to exist at higher rates among low-income and ethnic minority adults with hype rtension and diabetes wh en compared with the general population. Baumann et al. also underscored the critical and urgent need for prevention programs to address the lack of healthy lifes tyle behaviors (e.g., hea lth promoting nutrition behaviors and exercise be haviors) for low-income and other populations who are at high risk for hypertension. The prevention and management of hyperten sion and its related health conditions are issues of national concern. Nati onal initiatives such as Healthy People 2010 (2000) and JNC 7 (2003) include a call for health a nd health care research ers and providers to aid in finding ways to reduce the level of health ri sks associated with hypertension and its related health conditions.
25 Researchers recognize and are concerned that the adoption of recommended lifestyle modifications (e.g., healthy lifestyle behaviors) may be harder for certain groups in the general population than others, which makes better nati onal blood pressure control rates harder to achieve. The following factors were listed in the JNC 7 as potential barriers to low-income and African American individuals engaging in health promoting behaviors (e .g., nutrition behaviors): (a) cultural norms, (b) lack of availability of healthy food c hoices in schools, worksites, and restaurants, and (c) higher cost of food products that are lo w in sodium and calories. Lifestyle modifications including health pr omoting nutrition behaviors in addition to pharmacological treatment are often recommende d by health care providers to prevent or minimize the onset of negative health consequen ces from hypertension. M odifications to health behaviors for people diagnosed w ith or at high risk for high bl ood pressure include (a) aerobic physical activity, (b) dietary modification (e.g., health promoting nutrition behaviors), (c) smoking cessation, and (d) weight loss if ove rweight (Baumann, Chang, & Hoebeke, 2002). Research findings conducted on the adoption of recommended lifestyle modifications have concluded that such modifications are associated with a significant reduction in blood pressure, prevention or the delay of hypertension incidence and its related health conditions, enhancement in antihypertensive drug efficacy, and a major decr ease in cardiovascular diseases (e.g., kidney disease, stroke, congestive heart failure, and renal disease). Furt hermore, one group of researchers have documented that lifestyle nutrition modifications such as limiting the intake of salt and alcohol and eating a diet that emphasizes vegetables, fruits and low-fat or fat-free dairy products can reduce systolic and diastoli c blood pressure readings by 3.5 and 2.1 mmHg, respectively (Appel, 2003; Rankins, Sampson, Br own, & Jenkins-Salley, 2005; Svetkey, Harsha, Vollmer et al., 2003).
26 In studies that have implemented the Diet ary Approaches to St op Hypertension (DASH) Diet, which includes fruits, vege tables, and low-fat dairy products with a reduced content of dietary cholesterol, the individual that followed this diet have shown significant changes in blood pressure readings and overall dietary intake (Appel, 2003; Appe l, Champagne, Harsha, Cooper, & Obarzanek, 2003; Rankins, Sampson, Brown, & Jenkins-Salley, 2005). Additionally, researchers report that the effects of the S odium DASH Eating Plan, which emphasizes limiting intake of salt, are similar to the effects of a single drug therapy and that the combination of the two treatments as compared to either alone can result in even better blood pressure reduction results (NIH, 2003). Barriers to Healthy Nutrition Behaviors Amo ng African American Women Currently, evidence shows African American women have poorer nutrition habits and higher rates of obesity when compared to ot her gender and ethnic groups (Flegal, Carroll, Ogden, & Johson, 2002). Specifically, African Ameri can women eat fewer fruits and vegetables when compared to non-Hispanic Whites (Bas iotis, Carlson, Gerrior, Juan, & Lino, 1997). Although African American women understand the im portance of a healthy diet, they are not always able to translate their understanding into recommended lifestyle practices. It was reported that African American women consume more fat than is recommended by the American Heart Association even when they report avoida nce of high fat foods (Daroszewski, 2004). Food preferences and traditional food prepar ation practices that persist among African Americans may contribute to at-risk factors asso ciated with the dispr oportionate development and prevalence of hypertension and related health conditions ( diabetes, high blood cholesterol, and coronary heart disease) among low-income African American wome n (Gates & McDonald, 1997). Although changes in nutri tion behaviors are components of lifestyle modifications recommended by health care providers for the prevention and treatment of hypertension and
27 related health conditions, compliance to this component is challe nging among low-income African American women. Currently, theories and research on factors that influence adoption of recommended lifestyle modifications among lo w-income and ethnic minority groups have highlighted the following possible factors: (a) cultural differences in diet, (b) differences in perceptions of health care treatmen t, and (c) the impact of stress. Focus group studies have provided informa tion on barriers to and cultural perceptions regarding nutrition behaviors among African American males and females. In a focus group study exploring the cultural factors that constitute active or latent influences on the potential for dietary change among lowand middle-i ncome African American women and men, Airhihenbuwa and Kumanyika (1996) found that among these African Americans, the influences of slavery and economic disadvantages may be cont ributors to the consumption of diets that are high in total fat, saturated fat, and salt among their participants. Horowitz, Tuzzio, Rojas et al. (2004) used focus groups to identify knowledge, attitudes, and beliefs concerning lifestyle changes and barriers to adhering to lifestyle changes among urban African American and Latino men and women treated for hypert ension. These researchers found that a number of barriers related to dietary modification a dherence were identified, and thes e barriers include the expense of maintaining a healthy diet, reluctance to de part from traditional and preferred diets, and feelings of isolation during social functions involving cultural foods In addition to these barriers, participants found clinic ian-recommended diets for hypertension to be indirect and difficult to follow. Hargreatves, Schlundt, and Buchowski (2002) also used focus groups to identify patterns and contexts of every day eating behaviors of Af rican American women. Participants from this study indicated that moods, stress, and emotions can influence what and how much food they
28 consumed. The over-consumption of fat and calor ies based on negative emotions was suggested as a possible contributor to poorer diets and increased disease risk found among African American women. Gates and McDonald (1997) found that African American women had less positive attitudes toward nutrition when comp ared to non-Hispanic White women and both groups agreed that there were too many dietar y recommendations and that making recommended changes is expensive. Additionally, it was found that the African American women in the Gates and McDonald study consumed less heart healt hy diets, reported less awareness of the relationship between nutrients and health problems, and had less knowledge about food sources of fat and cholesterol than non-Hispanic White women. The above mentioned studies hi ghlight potential factors associ ated with health promoting nutrition behaviors among African Americans, part icularly those of African American women. The examination of factors that influence nutri tion behaviors among this group may be essential for establishing interventions that can eventua lly increase health promoting nutrition behaviors among African American women diagnosed with or at-risk for hypertension and related health conditions (Airhihenbuwa & Ku manyika, 1996; Gates & McDonalds, 1997). Horowitz et al. (2004) also suggest that low-income African Americans with hypertension may benefit from culturally sensitive approaches to dietary modification. Thus, a major focus of the present study was to examine psychosocial factors (stress and patient-centered cultural sensitivity in the health care experienced) that influence level of nutrition behavi ors among low-income African American women patients diagnosed with or at -risk for hypertension and/or related health condition (diabetes, high blood pressu re, and coronary heart disease). Stress Lazarus and Folkm an (1984) set forth a widely known psychological conceptualization of stress. They stated that stress is the appraisal of an individual exposed to a noxious environment
29 which threatens to deplete their resources or endanger their well-being (Lazarus & Folkman, 1984). Furthermore, the concept of coping was in troduced in their defin ition of stress. Coping was defined as the bodys way of managing psychological stress. Lazarus and Folkman acknowledged that resources available for coping such as growth of competence and the joy of triumph against adversity need to be account ed for when measuring stress (p. 3). More specifically, Lazarus and Folkman defined stress as a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being (p.19). In their Cognitive Appraisal Framework, Lazarus and Folkman (1984) emphasize the person-environment interaction a nd cognitive appraisal as major components of stress. Cognitive appraisal is defined as the assessment of the c ognitive processes of an individual in relation to their surroundings, or more spec ifically, the assessment of th e person-environment interaction. Cognitive appraisal can occur in three steps: primary appraisa l, secondary appraisal, and reappraisal. The first step, prim ary appraisal, is an individual s assessment of an event and whether they define the encounter as irrelevant, benign-positive, or stressful. Individuals who encounter irrelevant events have nothing to ga in or lose, and therefor e these events carry no implication regarding stress. Benign-positive ev ents are encountered by the individual as positive, and thus these events enhance and pres erve well-being. Finally, stressful events can take three forms: harm/loss, threat, and challenge. Harm/lo ss is described by Lazarus and Folkman as damage the individual has already sustained, whereas, thr eat is described as anticipated harm or loss. Lastly, challenge refers to events that hold the possibility for mastery or gain. The second step, secondary appraisal, invo lves the concern regard ing what might and can be done. The individual must determine if a part icular coping option will accomplish what needs
30 to be done and whether to apply a particular st rategy or set of strategies effectively. Based upon the consequences of utilizing a particular stra tegy, an evaluation will occur. The last step, reappraisal, refers to a change d appraisal based on new information from the environment and/or the person. Several studies on the concept of stress have resulted in modified versions of Lazarus and Folkmans (1984) Stress and Coping Framework to explain the negative health outcomes influenced by racism and/or discrimination ex perienced by African Americans. Outlaw (1993) proposed a modification to this cognitive appraisa l framework that elimin ates the benign-positive and irrelevant cognitive apprai sal choices. Outlaw claims that the unpredictable and uncontrollable acts of racism do not allow African Americans to asse ss the act of racism as either benign or irrelevant. Outl aw further claims that by eliminating the appraisal choices, racism can only be considered a chronic and continuous stre ssor stemming from heightened awareness in which all situations are consciously and unc onsciously evaluated. Therefore, according to Outlaws proposed stress model, the response to and evaluation of raci st encounters can be viewed as harmful, threatening, or challenging. Consistent with Outlaws (1993) proposed st ress model, Clark, Anderson, Clark and William (1999) presented another tailored model to test the biopsychosocial effects of perceived racism. This model postulates the following: The perception of an environmental stimul us as racist results in exaggerated psychological and physiological stress respons es that are influenced by constitutional factors, sociodemographic factors, psychological and behavioral factors, and coping responses. Over time, these stress responses are posited to influence health outcomes. Furthermore, the perception of environmental stimuli as racist and ensuing coping responses are postulated to be a function of a complex interplay between an array of psychological, behavioral, constitutional, and sociodemographic factors (p. 806).
31 Clark et al. (1999) claim th at African Americans are di sproportionately exposed to environmental factors that may be sources of chronic and acute stress. In their rationale, biological sequelae that follow after race-specific exposures are believed to account for disparities in health outcom es found among ethnic minority men and women. Both Outlaw and Clark et al.s modifications of Lazarus and Fo lkmans (1984) model imply that stress deriving from environmental stimuli consequently affect health outcomes among low-income African Americans. Low socioeconomic status (SES) has been a ssociated with higher exposure to harmful, threatening, and challenging situations that are perceived as stressf ul (Forman, William, & Jackson, 1997; Sigelman & Welch, 1991). Research has shown that low SES individuals are more vulnerable to stress when compared to high SES individuals, and the former have fewer coping resources (Feagin, 1991; Kessler, 1979; McLeod & Kessler, 1990). Baum, Garofalo and Yali (1999) also state that low-inco me individuals are placed in se ttings that are potentially more stressful or hazardous than the settings that hi gher SES individuals often experience. This is particularly noteworthy because African Am ericans are overrepresented in the low socioeconomic group of individuals in the U.S. (Winkleby, Kraemer, Ahn, & Varady, 1998). African American women, in particular, are more likely to experience stressful life conditions and to be more negatively affected by these stressors when compared to other ethnic groups (Thoits, 1995). Specifically, low-income, ethnic minority women may face unique stressors associated with finances and role demands of the household. African American women often face the burden of raising children in a sing le-parent household and experience the strain of being the sole economic provider for their fa milies (Schulz, Israel, Williams et al., 2000). Additionally, research evidence s hows that African American wo men are more likely to report
32 perceptions of unfair treatment within and outside of the health care environment when compared to other ethnic minoritie s and non-Hispanic Whites (refs). Schulz et al. (2000) cla im that relatively little research has specifically examined the particular stressors experienced by women of diffe rent racial groups, the relationships of these stressors to social contexts, and the ways that differences in thes e experiences may contribute to racial differences in womens health outcomes and behaviors. Schulz et al. utilized the Stress Process Framework to examine the differential di stribution of stressors by area of residence and the cumulative effects of these different life e xperiences on womens health status. Some of the notable findings of this study indicated that low-inco me African American women living in the inner city reported significantly more experiences with unfair treatment and acute life events ( likelihood of being a victim of a physical attack, death of someone close in the past year) than non-Hispanic White women living outside the ci ty. The research findings of Schulz et al. strongly support the conclusion that there ma y be multiple pathways through which chronic stressors due to discrimination and environmen tal conditions influence health outcomes and health behaviors among low-income African American women. Stress and Nutrition Behaviors The adoption of lifestyle nu trition modifications (health promoting nutrition behaviors) that is necessary to control blood pressure may be harder for lowincome and ethnic minority individuals for several reasons already cited earl ier in this literature review (Baum, Garofalo, & Yali, 1999; Clark et al., 1999; Griffin, Friend, Eitel, & Lobel, 1993; Schoenberg, 1997; Ward, Morisky, Lees, & Fong, 2000). Additionally, several conditions may prevent low-income and ethnic minority individuals from maintaining a diet that meets daily nutritional needs. Particul arly, stress derived from environmental stimuli or racial status has been implicated in health damaging and health pr omoting behaviors of th ese groups (Anderson &
33 Armstead, 1995). Baum, Garofalo and Yali (1999) support this contention by stating that excess chronic stress due to poor living conditions may limit the health promoting behaviors of lowincome individuals and thus increa se health damaging behaviors. Stress from the lack of priv ate transportation to grocery stores, long waiting lines at public clinics, crowded clinic conditions, the unaffordable cost of antihypertensive medications, and the inability to utilize public services such as child care have been cited as potential barriers to health care and health promoting behaviors among low-income, ethnic minorities (Baum et al., 1999; Weick, 1997). Even seeking food and shelte r may also take precedence over improving health and well-being among disadvantaged and impoverished groups (Weick, 1997). Lukoschek (2003) found that African American participants diagnosed with hypertension reported increased stress due to daily lives be ing challenged by incidents of racial profiling and prejudicial attitudes a nd viewed these daily encounters as a cause for the higher prevalence of hypertension (p. 581). Furthermore, Lukoschek concluded that among hypertensive African Americans, hostile living conditions coupled with intensified hypertensive responses to stressors often provoked by feelings of racial injustice, lead to increased rates of treatment nonadherence and expression of illness symptoms subsequent to medication intake. In another study conducted by Sanders Thompson (2002) investigating the experiences of stress and racism among low-income African Americans, it was concluded that SES may influence hypertension prevalen ce through health behaviors. Sa nders Thompson further states that changes in eating patterns, sleep, blood pres sure, and increased use of alcohol and other substances may occur in response to racial/ethnic discrimination, which can ultimately affect blood pressure. Baum et al. (1999) introduced the stress-healt h hypothesis which states that
34 stress and SES have similar affects on health be haviors and health outcomes and these factors appear to show similar patte rns when stress is high or SES is low (p. 139). Stress and Nutrition Behaviors Among African American Women Several studies (Clark, Anderson, Clark, & William, 1999; Outlaw, 1993; Thoitis, 1995) suggest that stress-inducing environments and the sociopolitical forces that pervade the lives of many low-income African Americans likely contribute to frustration, ange r, and psychosocial stress that may eventually impact preventative health care be haviors that lead to the preval ence of hypertension and related health conditions (e.g., diabetes, high blood cholesterol and coronary heart disease). Furthermore, some health care providers may fa il to recognize that it may be difficult for lowincome African Americans who experience stressful conditions on a daily basis to make lifestyle changes due to barriers to these changes that come with low-income status. Stress has been implicated as an influencing factor for adoption of recommended lifestyle modifications (e.g., changing dietary intake and managing weight) by minority women. However, only a few studies have explored psychological factors su ch as stress as an influence on African American women's rates of particip ation in risk reduction behaviors and health promoting behaviors. Researchers are calling fo r the examination of the relationship between stressors experienced by ethnic minority women and these womens engagement in health behaviors such as nutrition behaviors (Schulz, Israel, Williams et al., 2000). The following examples demonstrate some of the research th at has focused on psychosocial factors such as stress and their relationshi p to nutrition behaviors among African American women. Walcott-McQuigg (1995) found that stress infl uenced weight-control behavior (e.g., diet control, exercise, and weight management) in a group of middle-inco me African American women. More specifically, after time constraints, stress accounted for 56% of the variance in
35 engagement in weight-loss behaviors by African American women. Furthermore, stressful events resulted in stressful eating be havior for more than 50% of the women in the study. Artinian, Washington, Flack, Hockman, and Jon (2006) also found that African American women with higher levels of depression had higher diastolic blood pressure and were more likely to smoke, eat fewer fruits and vegetables, and have more stress and less social support. In another study by George, Milani, Hanss-Nuss, and Freeland-Graves (2005) to evaluate the compliance to recommended nutritional be haviors among low-income women (31.5% White, 30.1% African American, and 38.4% Hispanic) during late postpartum, it was found that stress was associated with less healthful diets a nd lifestyles among these women. The authors concluded that stress as a result of financial issues, loss of lo ved ones, and problems from work or school limited the ability of these women to adhere to recomme nded dietary guidelines including engagement in nutrition behaviors. Thus it is reasonable to believe that stress may impact compliance with dietary modifications of low-income African American women who are not only often responsible for the food choices an d well-being of the entire family, but who may also periodically encounter acts of racism in general and in th e health care setting. Patient-Centered Culturally Sensitive Health Care Cultura l sensitivity in health care has been de scribed as the ability to be appropriately responsive to the attitudes, feelings, or circum stances of groups of pe ople that share a common and distinctive racial, national, religious, linguistic, or cultural heritage (Office of Minority Health). Definitions of cultural sensitivity from schools of public health al so include the extent to which ethnic/cultural characteristics, expe riences, norms, values, behavioral patterns and beliefs of a target population as well as relevant historical, envi ronmental and social forces are incorporated in the design, deliv ery and evaluation of targeted health promotion materials and programs (Resnicow, Baranowski, Ahluwa lia, & Braithwaite, 1999, p. 11). In a study
36 examining the communication between health care providers and ethnically different patients, cultural sensitivity in health care was defined as involving a willingness to use cultural knowledge while interacting with patients, a nd considering culture during discussions and recommendations for treatment (Ulrey & Am ason, 2001, p. 450). Culturally sensitive health care has also been described by Majumdar, Browne, and Roberts ( 2004) as care in which health care providers give their services in a manner that is relevant to patients needs and expectations. According to Tucker, Mirsu-Paun, van den Be rg, et al. (in press) patient centered culturally sensitive health care emphasizes displaying patient-desired modifiable provider and office staff behaviors and attit udes, implementing health care center policies, and displaying physical health care center charact eristics and policies that cultura lly diverse patients identify as indicators of respect for their culture and that enable these patients to feel comfortable with, trusting of, and respected by their health care providers and office staff. Furthermore, Herman, Tucker, Ferdinand, et al. (in press) also posited that patient-centered culturally sensitive health care not only encompasses the meaning of cultural competence but moves beyond this meaning by emphasizing patient centeredness (p. 8). Patient centeredness is when the patients want s, needs, perceptions, and feelings inform the health care delivery process and that the patients feelings of in terpersonal control and empowerment are fostered. Thus, patient-centered cu lturally sensitive health care as proposed by Tucker et al. (in press) emphasi zes the display of specific behavi ors, attitudes, and knowledge, and the creation and implementation of physical health care characterist ics and policies that culturally diverse patients re ported as important in hea lth care experienced. Clearly, understanding the role of patient -centered culturally se nsitive health care in low income and minority primary care patients health outcomes is needed, as this understanding will inform
37 needed interventions to promote health among thes e patients (Tucker, Herman, Ferdinand et al., in press). Patient-Centered Culturally Sensitive Health Care and Nutrition Behaviors. In addition to basing culturally sensitive hea lth care on the perspectives of cu lturally diverse patients such as African American women, Tucker et al. (in pres s) also emphasize the importance of evidencing provider and staff behavi ors/attitudes and clinic characte ristics that are modifiable and measurable and that are desired and identified by pa tients (p.9). Of particular importance to the present study is Tuckers proposed Patient-C entered Culturally Sensitive Health Care (PCCSHC) Model which proposes linkages between patient-perceived, patient-centered culturally sensitive health care variables (provider behavior s/attitudes, office staff behaviors/attitudes, and health care center characteristics and policies) and patients engagement in a health promoting lifestyle (e.g., eating a nutriti ous diet, exercising) and heal th outcomes (Tucker, Herman, Ferdinand et al., in press). In sum, this model asserts that (a) patien t and provider training can promote patientcentered culturally sensitive hea lth care as indicated by physical environment characteristics of the health care center, provider behaviors/attitude s, and office staff behaviors/attitudes; (b) this care influences patients percei ved levels of provider cultural sensitivity and interpersonal control--both of which impact patients level of engagement in a health promoting lifestyle and level of health care satisfaction; (c) the latter in fluences patients level of treatment adherence; and (d) both level of treatment adherence and level of engagement in a health promoting lifestyle directly influence patients health outcomes/statuses. Tuckers PC-CSHC Model is consistent with the view of others that patient-perceived cultural sensitivity in the health care they experi ence can thwart or influence the compliance to
38 treatment behaviors and ultimately health outc omes of patients (Lukoschek, 2002; Rose, Kim, Dennison & Hill, 2000; Tschann, Adamson, Coates, & Gullion, 1988). In particular, low compliance to treatment adherence behaviors displayed by ethnically and racially diverse patients is suggested by researchers to be a resu lt of limited levels of cu lture-related knowledge, skills, experience, and awaren ess demonstrated by their heal th care providers (Shapiro, Hollingshead, & Morrison, 2002). Johnson, Saha, Arbelaez et al. (2004) found in their study of 6,299 primary care patients (3,488 non-Hispanic Whites, 1,037 African Americans, 1,153 Hispanics, and 621 Asians) that African Americans, Hispanics, and Asians we re significantly more lik ely than non-Hispanic Whites to agree that (a) they would receive better care if they be longed to a different race/ethnicity, (b) medical staff judged them unfai rly or treated them with respect based on how well they spoke English, and (c) medical staff judged them unfairly or treated them with disrespect based on their race/ethnicity. Furthermore, ethnic minor ity patients were significantly more likely than non-Hispanic White patients to perceive health care system biases and deficiencies in cultural competence in this study. The authors assert that improvement in patientprovider communication may improv e patient ratings of interpersonal bias and cultural competence of physicians. Patient-Centered Culturally Sensitive He alth Care and Nutrition Behaviors Among African American Women Researchers suggest that health care systems and health care providers behaviors and attitudes that are perceived as ineffective, inappropriate, and culturally insensitive account for some of the health disparities found among ethni c minorities (Tucker, Herman, Pedersen et al., 2003). For example, Lukoschek (2002) found th at adherent African American participants were more likely to descri be their physicians as receptive to and able to
39 address their concerns and able to provide he alth information, whereas nonadherent African American participants were more likely to de scribe their physicians as ignoring them as individuals, not addressing their concerns, and withholding information. Furthermore, Lukoschek stated that patients who render themselv es amenable to behavioral change do so once physicians integrate the patients culturally specific health belie fs into the health information provided. In another study, Die Trill and Kovalcik ( 1997) found that noncompliance to treatment recommendations and misinterpret ation of medical information wa s the result of complex crosscultural issues between et hnically different patients and thei r providers. This study also suggests that there is a link between culturally sensitive health care and the health behaviors of ethnic minority patients. Additionally, Melkus et al. (20 04) posit that ethnic minority patients such as African American women may be less successful at weight loss or disease management interventions when they are traditional or non culturally specific (p. 11). Hence, research evidence strongly supports the impl ementation of interventions that are culturally sensitive and appealing when geared toward weight loss or dietary modifications of African Americans (Schoenberg, 1997; Melkus et al., 2004). The present study is of particular importance to the literature because only a few studies have focused on patient-centered cultural sensitiv ity in the health care experienced by African American men and women. Moreover, the associations between perceived cultural sensitivity in health care experienced and e ngagement in health promoti ng behaviors such as nutrition behaviors have not been well examined. Yet, su ch behaviors are often recommended by health care providers to treat or prevent hypertension, diabetes, obes ity, cancer and numerous other health problems. Given that women are usually considered the family gatekeepers for health
40 and dietary intake (Melkus et al., 2004, p. 11), and given the higher prevalence of many of the major chronic health problems among African American women than among other racial/ethnic groups of women, the focus of present study on examining factors in the health promoting nutrition behaviors of African Amer ican women is clearly justified. Summary The review of the literature on stress patient-centered culturally sensitive health care, and nutrition behaviors and their asso ciations suggests that the lack of engagement in health promoting behaviors such as health promoting nutrition behaviors is one of the main barriers to achieving controlled blood pressu re among African Americans in general and African American women in particular. African American wome n, in particular, often have most of the responsibility of providing healthy food choices for themselves and for their families, which make these women important targets for health promotion interventions. In order to design effective interventions to promote nutrition be haviors among African American women, factors associated with these behaviors among such women need to be further examined. Patient-perceived, patient-centered cultural sensitivity in health care experienced and perceived stress have been identifi ed in the literature as two possible factors associated with the adoption and maintenance of lif estyle modifications among low-income African American women. However, there has been limited research to examine these associations, particularly among women with or at risk for hypertension or associated health c onditions. Indeed, it is especially important for such women to enga ge in nutrition behavi ors as is typically recommended by their health care providers. Ther efore, the aim of th e present study is to examine both level of self-repor ted, patient-centered cultural sensitivity in health care experienced (provider behaviors/at titudes, office staff behaviors/at titudes, and health care center characteristics and policies) and level of self-re ported stress (behaviora l stress, cognitive stress
41 and physical stress) as factors in level of enga gement in nutrition behaviors among a sample of low-income African American women primary care patients diagnosed w ith or at risk for hypertension and/or related health conditions (d iabetes, high blood cholesterol, and coronary heart disease). A secondary aim of the present study is to determin e if Tuckers Patient-Centered Culturally Sensitive Health Care (PC-CSHC) Mode l should be modified to include stress as a separate predictor of patients self-reported level of engagement in a health promoting lifestyle. Hypotheses and Research Question The following hypothes es will be tested: (1) Among low-income African American women patients diagnosed with or at risk for hypertension and/or related health conditi ons (diabetes, high blood cholesterol, and coronary heart disease), self-re ported levels of stress (physical stress, behavioral stress, and cognitive stress) will have a significant negative association with self-reported level of nutrition behaviors. (2) Among low-income African American women patients diagnosed with or at risk for hypertension and/or related health conditi ons (diabetes, high blood cholesterol, and coronary heart disease), self-reported levels of patient-centered cultural sensitivity in the health care experienced (provide r behaviors/attitudes, office st aff behaviors/attitudes, and health care center characteristics and policies) will have a significant positive association with self-reported level of nutrition behaviors. In addition to the above hypotheses, the follo wing research question will be addressed: Are there significant age and educational attainment level differences in self-reported levels of stress (physical stress, behavioral stress, and cognitive stress), patient-centered cultural sensitivity in health care experienced (provider behaviors/attit udes, office staff behaviors/attitudes, and health care center char acteristics and policies), and nutrition behaviors among low-income African American women patient s diagnosed with or at risk for hypertension and/or related health conditions (diabetes, high blood cholesterol, and coronary heart disease)?
42 CHAPTER 3 METHODS Participants The wom en patient participants in the present st udy were part of a larg er project to test a Patient-Centered Culturally Sensitive Health Care Model with a sample of low-income culturally diverse primary care patients who utilized one of two community-based health care centers in close proximity within a small city community in northeast Florida. All of the African American women patients from this larger study served as participants for the pr esent study. A total of 269 patients qualified for and gave their written cons ent to participate in the larger study. Of those 269 patients, 153 (57%) were African American, and of these African Americans, 117 were African American women. Of the 117 consenting African American women patients, 80 women patients completed all of the measures of inte rest in the present study and thus formed the participant sample for this study. The sample for the present study ranged in age from 19 years, with a mean age of 51.34. The distribution of self-reported household in comes for the sample is as follows: (a) 61.3% earned below $10,000, (b) 12.5% earned be tween $10,001 and $20,000, (c) 10.0% earned between $20,001 and $30,000, (d) 5.1% earned a bove $30,001, and (e) 11.3% did not report a household income. The level of education distri bution for this sample based on self-reported educational attainment is as follows: (a) 16.3% did not attain a high school diploma, (b) 35.0% attained a high school diploma, (c) 21% attained some college education a higher educational level, and (d) 22.5% did not report their attained level of education. For purposes of the present studys research analyses, women patients were grouped as follo ws: (a) those with at most primary education (LE low), (b) those with high school education (LE average), and (c) those with at least some college education (LE high). Descriptive st atistics for other obtained
43 demographic characteristics of the participant sample includi ng for those mentioned above are listed in Table 3-1. The distribution of self-reported number of years since be ing told by a health care provider about having high blood pressure for th e studys sample is as follows: (a) 22.5% reported 0 1 year, (b) 21.3% reported 2 3 ye ars, (c) 26.3% reported 4 9 years, (d) 21.3% reported 10 years or more, and (e) 8.8% did not report number of years. The distribution of selfreported diagnosed health conditions is as fo llows: (a) 23.8% reported being diagnosed with hypertension alone, (b) 32.5% repor ted being diagnosed with hypertension and at least one other related health condition (diabetes, high blood chol esterol, or coronary heart disease), (c) 6.3% reported being diagnosed with diabetes alone, and (d) 1.3% reported bein g diagnosed with high blood cholesterol alone. In addi tion, 18.8% of women patients re ported being diagnosed with hypertension and/or a related h ealth condition (diabetes, high blood cholesterol, or coronary heart disease) as well as one or more unrelated health conditions (asthma, anemia, and arthritis), and 17.5% did not report any diagnosed health conditions. The office staff at the two participating hea lth care centers identified possible patient participants based on the following inclusion criteria: (a) is 18 y ears or older, (b) has received health service at one of two partic ipating health care centers at least 3 times in the year prior to the research, (c) identifies as African American, (d) has high blood pressure, with or without another chronic health problem (d iabetes, high blood cholesterol or coronary heart disease) for at least one year prior to the proposed research, (e) is able to communicate effectively with others verbally or in writing in her or his native language, and (f) gives witness-verified written consent to participate.
44 Measures In the larger study, participants were aske d to anonym ously complete an assessment battery (AB) consisting of 12 brief study questio nnaires. Only six of these 12 questionnaires were included in the AB for the present study to assess the variables of interest. These six questionnaires are as follow: (a ) a Demographic Questionnaire, (b ) a Medical Data Sheet, (c) the Nutrition Subscale of the Health Promoting Life style Profile, (d) the Marlowe-Crowne Social Desirability Scale, (e) the Stra in Questionnaire, and (f) the Tucker Cultura lly Sensitive Health Care Inventory African American Patient Form. Demographic Data Questionnaire A De mographic Data Questionn aire (DDQ; see Appendix A) was constructed by the Principal Investigator for the larger study to obtain information about each participant including age, annual household income, highest level of education completed, marital status and employment status. Medical Data Sheet A Medical Data Sheet (MDS; see Appendix B) was constru cted by the Principal Investigator for the larger study to obtain sele cted self-reported medical data on each patient including the following data: (a) number of years since being told of high blood pressure, (b) diagnosed illness(es), and (c ) other recommended treatments for high blood pressure. Health Promoting Lifestyle Profile The Health Prom oting Lifestyle Profile (HPLP; see Appendix C) is a 52 item scale that measures overall level of engagement in health promoti ng behaviors which indicate self-initiated actions/behaviors that serve to maintain or en hance ones level of welln ess, self-actualization, and fulfillment of the individual (Walker, Sechrist, & Pender, 1987).The HPLP is comprised of six subscales (self-actualization, health responsib ility, exercise, nutrition, interpersonal support,
45 and stress management); however in the present study only the Nutrition Subscale of the HPLP was utilized. Reports of the test-retest reliabi lity for the nutrition subscale have ranged from .81 to .91 (Walker et al., 1987). Nine items comprise the Nutrition Subscale of the HPLP, which include the following sample items: Eat 2-4 servings of fruit a day and R ead labels to identify nutrients, fats, and sodium content in packaged food. Ratings on the Nutrition Subscale and the other HPLP Subscales are made using a Likert-type scale where 1 = Never, 2 = Sometimes, 3 = Often, 4 = Routinely indica te level of engagement in the behavior. Overall scores for the HPLP and its subscales are obtained by calcula ting the mean. Higher scores on the measure indicate higher levels of engagement in health promoting behaviors. Marlowe-Crowne Social Desirability Scale The Marlow e-Crowne Social Desirability S cale (MCSDS, see Appendix D) is a 20-item scale that measures the degree to which partic ipants respond in a so cially desirable manner (Crowne & Marlowe, 1960). The MCSDS has Kuder-Richardson 20 (KR-20) reliability coefficients of .83 for college females and .78 for college males. Additionally, Fraboni & Copper (1989) and Strahan & Gerbasi (1972) have found the MCSDS to be a valid measure. Respondents are instructed to mark True or False to ten items keyed in the true direction and ten items keyed in the false direction. Scores ra nge from zero to 20 with higher scores indicating higher levels of influence of so cial desirability in completi ng the Assessment Battery. Sample items from the MCSDS are Im always willing to admit it when I make a mistake and I have never intensely disliked anyone. Strain Questionnaire The Strain Questionnaire (SQ, see Appendix E) is a 48-item scale that m easures overall health-related stress and the three components of this overall stressbehavioral stress, cognitive stress, and physical stress (Lefebvre & Sandfor d, 1985). The SQ has been reported by the authors
46 to have good internal consistenc y (alphas = .71 .94) and high c oncurrent validity (Main et al., 1987). The instruction on the SQ is to indicate the number of days that the listed items are experienced during the stated time frame. Item re sponses on the SQ are as follows: A = Not at all (0 days), B = Rarely (1 days), C = Sometimes (3-4 days), D = Frequently, (5-6 days), and E = Everyday (7 days). Ratings are made using a scale where A = 1, B = 2, C = 3, D = 4, and E = 5. The SQ is scored by summing the rati ngs of the items to yield a total score. Lower total scores are associated with lower levels of stress, whereas higher total scores are associated with higher levels of stress. The following are sa mple items taken from the SQ: How often in the past week have you experienced or felt each of th e items listed? (a) Rac ing heart, (b) Use of alcohol, and (c) Believe the world is against you. Tucker Culturally Sensitive Health Care In ventory African America n Patient Form The Tucker Culturally Sensitive Health Care Inventory African American Patient Form (T-CUSHCI AA, see Appendix F) is a 125item scale that measures the level of selfreported patient-centered cultural sensitivity in ones health care center environment (including physical and policy aspects of the environment) and in the behaviors and att itudes of ones health care providers and office staff (T ucker, Mirsu-Paun, van den Berg et al., in press). It has been reported by the author of the T-CUSHCI-AA to have good internal c onsistency (Chronbach alpha = .98). Additionally, six-m onth test-retest reliabilities for its Provider Behaviors and Attitudes, Office Staff Behaviors and Attitudes, and Center Policies and Physical Environment Characteristics components were .99, .98, and .97, resp ectively; the split half reliabilities were .90, .87, and .95, respectively; and the Alpha co efficients were .98, .95, and .97, respectively (Tucker et al., in press).
47 The T-CUSHCI-AA consists of three compone nts: (1) Health Care Provider Behaviors and Attitudes (behaviors and at titudes that promote patient trust and comfort, and feeling respected), (2) Health Care Offi ce Staff Behaviors and Attitudes, and (3) Health Care Center Characteristics and Policies (phys ical environment and policy char acteristics). Ratings are made using a scale where 4 = Strongly Agree, 3 = Agree, 2 = Disagree, and 1 = Strongly Disagree. Scores for this measure are averaged to yield a mean score for each component. Higher mean scores are associated with greater se lf-reported levels of pa tient-centered cultural sensitivity, whereas lower scores are associated with lower self-reported levels of patientperceived, patient-centered cultural sensitivity. Th e following are sample items taken from the TCUSHCI-AA: (a) The person I see most often for my health care when I visit my clinic: Has training in working with African American patients (b) The Clinic staff members at my clinic: Do not stereotype African Amer ican patients as unable to read and uneducated, and (c) My health care clinic: Has brochures available about illnesses or diseases common to African Americans. Procedure Participants were a sub-sam ple of those recruited from two community-based primary care health care centers in northeast Florida fo r a larger study to test a Patient-Centered Culturally Sensitive Health Care Model. Specifically, the data obtained from the African American women patients who completed the measur es of interest to th e present investigator were used in the present study. The following two methods were used to recruit patient participants for the larger st udy: (a) a health care center offi ce staff mailing method and (b) a recruitment poster display in the par ticipating health care centers method.
48 In the health care center office staff maili ng method, patient participants who met the participant inclusion criteria (i.e ., is 18 years or older and identif ies as African American) were identified by the participating health care center representatives (i.e., the ce nter director and data manager). These professionals mailed each of the patients an invitation packet. The invitation packet consisted of the following material: (a) a cover letter signed by the Principal Investigator and one co-investigator (a health care center representative) of th e larger study a letter that detailed the research purpose, participation instructions, and precautions taken to ensure participants confidentiality (s ee Appendix G), (b) two copies of an Informed Consent Form (Appendix H), (c) a Demographic Data Questionna ire (DDQ), and (d) a stamped pre-addressed envelope for returning the Informed Consent Form and the DDQ. The health care center representatives did not disclose th e identity of these potential pati ent participants to researchers. Upon receipt of the signed patient Informed Consent Form and completed patient DDQ, the researchers mailed that patient a questionnaire packet consisting of the following materials: (a) a cover letter that included permission to and inst ructions for receiving a ssistance (i.e., receiving assistance in completing the ques tionnaire packet from a family member or friend, or having a researcher verbally administer the AB while they attended their perspective health care center; see Appendix I) (b) the Assessmen t Battery (AB); (c) a payment release form to receive a $20 participation incentive within th ree weeks of their research par ticipation, and (d) a pre-addressed and pre-stamped envelope for returning the comp leted versions of the AB and payment form. In the poster recruitment method, participants were recruited via recruitment posters placed at both the intervention health care center (i.e., Eastside Commun ity Clinic located in Gainesville, Florida) and control health care cen ter (i.e., Family Medical Practice Group located in Gainesville, Florida) for the larger study. The poster (a) informed patient s that a University of
49 Florida based research team requested their par ticipation in a study to examine ways to improve the health care and support they experience from their health care provid ers, (b) specified the patient participant inclusion criteria, (c) indica ted that patients would be mailed a payment of $20 within three weeks of their rese arch participation, (d) instructed patients to complete contact information slips, which were attached to the poster and requested the patients name, gender, race/ethnicity, telephone number, and address, and (e) instructed patients to place completed contact information slips into an envelope attach ed to the poster. The slips were periodically collected and mailed to the researchers by a volunt eer staff member at each of the participating health care centers. Researchers then mailed an invitation packet to each patient whose contact information slip indicated that she/he met the participation inclusion criteria. This invitation packet contained the same materials earlier desc ribed in the health care center office staff mailing method. Those patients who returned a signed copy of the informed consent form and a completed DDQ were also mailed the above desc ribed AB. Patients who returned a completed AB were each mailed $20 within three weeks of receiving this packet. The order of the forms and questionnaires in the AB were always counterbalanced for order with the cover letter appear ing first, and the Demographic Data Questionnaire and Payment Release Form appearing last. To ensure patien t confidentiality, questionn aires were pre-coded and names matching codes were kept in a separate locked file from the coded data in compliance with IRB regulations.
50 Table 3-1 Descriptive statistics for the demographic variables in the present study Note Age range = 19 85 years, Age mean = 51.34, Age SD = 13.09 Variable N % Household income Income of < $10,000 49 61.3% Income of $10,001 $20,000 10 12.5% Income of $20,001 $30,000 08 10.0% Income of > $30,000 04 05.1% Education level N o high-school diploma 13 16.3% High school diploma 28 35.0% Some college education or more 21 21.0% Marital status Single, livi ng without a partner 30 37.5% Single, living with a partner 07 08.8% Married, living without a partner 12 15.0% Married, not living with a partner 04 05.0% Divorced or separated 13 16.3% Widow/widower 07 08.8% Work status Do not work 55 68.8% Work part time 11 13.8% Work full time 12 15.0% Self-diagnosis Hypertension alone 19 23.8% Hypertension plus 26 32.5% Diabetes alone 05 06.3% High blood cholesterol alone 04 05.0% Coronary heart disease alone 01 01.3%
51 CHAPTER 4 RESULTS This chapter describ es the results of the analys es to test the hypotheses and results of the analysis to examine the research question set fo rth in the present study. This chapter is divided into the following main sections : (1) Descriptive data for the major variables of interest and social desirability, (2) Co rrelations between the major variables of interest a nd social desirability, (3) Results from the analyses to test Hypotheses 1 and 2, and (4) Results from the analyses to test the research question. Descriptive Data for the Major Variable s o f Interest and Social Desirability The mean scores and standard deviations for each major variable of interest and social desirability are provided (Table 4-1). The major variables of interest are as follows: (a) stress predictor variables (behavioral stress, cogniti ve stress, and physical stress), (b) the patientcentered culturally sensitive health care predic tor variables (provider behaviors/attitudes, office staff behaviors/attitudes, and h ealth care center characteristics and policies), and (c) the nutrition behaviors criterion variable. Lowincome African American wome n patients in the present study had slightly lower mean nutrition behaviors scor es when compared to the norm mean nutrition behaviors scores of African American female and male smokers (Johnson, 2005, Table 4-1). The mean scores on the behavioral stress, cognitive stress, and physical stress variables for African American women patients in the present study te nded, on average, to be lower than the norm mean scores for a predominately white and higher socioeconomic sample (Lefebvre & Sanford, 1985).The mean scores on the patient-centered cultu rally sensitive health care variables (provider behaviors/attitudes, office staff behaviors/attitudes, and health care center characteristics and policies variables) revealed so me noteworthy trends. Specificall y, mean scores for the Provider Behaviors and Attitudes variable were relatively higher than the mean scores for the Office Staff
52 Behaviors and Attitudes and for the Health Care Center Characteristics and Policies variables for the African American women patients in the pr esent study. Finally, mean scores on the social desirability variable were also relatively high for the African American women patients in the present study. Correlations between Major Variables of Interest and S ocial Desirability Prior to conducting the analyses, a prelimin ary Pearson product-moment correlation was conducted to determine if there was a need to co ntrol for social desirability in the statistical analyses to test the hypotheses and research question. Scores on the fo llowing variables were included in this preliminary correlation: (a) pa tient-centered cultural sensitivity in health care experienced as indicated by scores for the provider behaviors/at titudes, office staff behaviors/attitudes, and health care center character istics and policies variables, (b) scores on the physical stress, cognitive stress and behavioral stress variable s, (c) scores on the nutrition behaviors variable, and (d) scores on the social desirability variable. Results of the correlation analysis (shown on Table 4-2) revealed that so cial desirability did not have a significant correlation with any of the major variables of interest. This result suggests that the African American women patients in this study did not respond in a socially desirable manner. Therefore, social desirability was not included as a covari ate in the analyses c onducted to test the two hypotheses and the one research que stion set forth in this study. Results from the Analyses to Test Hypotheses 1 and 2 Hypothesis 1 states that am ong low-income African American women patients diagnosed with or at risk for hypertension and/or related he alth conditions (diabetes, high blood cholesterol, and coronary heart disease), self-re ported levels of stress (physica l stress, behavioral stress, and cognitive stress) will have a sign ificant negative association with self-reported le vel of nutrition
53 behaviors. A multiple regression was performed to test Hypothesis 1. In this regression analysis, the predictor variables were se lf-reported levels of behavior al stress, cognitive stress, and physical stress. The criterion variable was self-re ported level of nutrition behaviors. Behavioral stress, cognitive stress, and physical stress we re simultaneously entered into the model. Regression diagnostics revealed no significant co ncerns regarding multicollinearity (VIF ranged from 1.46 to 1.86; Tolerance ranged from 0.54 to 0.68). The model containing all three pred ictor variables was significant (R2 = 0.22, F (3, 73) = 6.68, p < .01). In terms of significant unique predicto r variables in the regr ession model, physical stress, cognitive stress, and behavioral stress significantly explained 0.1%, 12.9%, and 13.6% of the variance in scores on the nutrition behavior s variable, respectively. The data in Table 4-3 indicate that as scores for th e behavioral stress variable ( t  = -2.21, p < .05) and the cognitive stress variable ( t  = -2.23, p < .05) increase, scores on th e nutrition behaviors variable decrease, thus providing support for Hypothesis 1. However, as indicated by Table 4-3 as scores for the physical stress variable ( t  = 2.21, p < .05) increase, scores on the nutrition behaviors variable also increase, which fails to support Hypothesis 1. Hypothesis 2 states that among low-income African American women patients diagnosed with or at risk for hypertension and/or related he alth conditions (diabetes, high blood cholesterol, and coronary heart disease), self-re ported levels of patient-centere d cultural sensitivity in health care experienced (provider behaviors/attitudes, offi ce staff behaviors/attitudes, and health care center characteristics and policies) will have a significant positive association with self-reported level of nutrition behaviors. A multiple regres sion was performed to test Hypothesis 2. The predictor variables were scores for provider beha viors/attitudes, office staff behaviors/attitudes, and health care center characteri stics and policies that serve as indicators of patient-centered
54 cultural sensitivity in health care experienced. The criterion variable was self-reported level of nutrition behaviors. The provider behaviors/attitudes, office staff be haviors/attitudes, and health care center characteristics and policies variables were simultaneously entered into the model. Regression diagnostics revealed no significant co ncerns regarding multicollinearity (VIF ranged from 2.88 to 4.06; Tolerance ranged from 0.25 to 0.35). The model containing all three predictor variables was not significant ( R2 = 0.03, F (3, 75) = .88, p = .46). It is thus concluded that provider behaviors/attitudes, office staff behaviors/attitudes, and health care center characteristics and policies that serve as indicat ors of patient-centered cu ltural sensitivity in health care experienced do not uniquely explain a significant amount of variance in the nutrition behaviors of the low-income African American women patients in this study. These results fail to provide support for Hypothesis 2. Results from the Analyses to Test the Research Question The research question set forth in this st udy was also addressed. This question is as f ollows: Are there significant age and educational attainment level differences in self-reported levels of stress (physical stress, behavioral stress, and cognitive stress), leve l of patient-centered cultural sensitivity in health care experienced (provider behaviors/attitudes, office staff behaviors/attitudes, and health care center charact eristics and policies), and level of nutrition behaviors among low-income African American wo men patients diagnosed with or at risk for hypertension and/or related health conditions (d iabetes, high blood cholesterol, and coronary heart disease)? Hierarchical multiple regression analyses were conducted to address this research question. Because preliminary Pearson correlation analyses revealed high positive correlations between the three patient-centered cultural sensi tivity in the health care (PC-CSHC) scores, an overall total score was used to represent these scores in the multiple regression analysis
55 involving the patient-centered cu lturally sensitive health care va riable. Five separate multiple regression analyses were performed. Scores for one of the following variables was the criterion variable in each multiple regr ession: PC-CSHC, Physical Stress, Behavioral Stress, Cognitive Stress, and Nutrition Behaviors. Age, Educati on Attainment Level (EAL), and Age EAL were used as predictor variables. Problems associated with multicollinearity were reduced by centering the predictor variable age before computi ng the interactions (Aiken & West, 1991; Cohen, Cohen, West, & Aiken, 2003; Keith, 2006). Educational Attainme nt Level was dummy-coded with two dummies (EAL average and EAL high), with EAL low de signated as the reference category (Aiken & West, 1991; Keith, 2006). Variables were entered in the regre ssion equation in blocks: the centered age predictor and the two dummy-coded va riables for EAL were entered first, followed by the product terms between the centered ag e predictor and each of the two dummy-coded variables (Aiken & Wet, 1991; Keith, 2006). The multiple regression model with PC-CSHC scores as the criterion variable was nonsignificant, R2 = .024, F [2, 52] = .744, p = .480. The multiple regression model with physical stress scores as the criteri on variable was also nonsignificant, R2 = .059, F [2, 52] = 1.622, p = .207. The multiple regression model with Be havioral Stress scores as the criterion variable was significant. A si gnificant Age EAL interaction was found, which explained 11.6% of the variance in Behavioral Stress above a nd beyond the variance explained by the first-order effects, R2 = .116, F [2, 52] = 3.575, p < .05. Tests of individual sta ndardized beta coefficients revealed that the Age EAL high interaction was a significant predictor of Behavioral Stress ( = .501, p = .01), whereas the Age EAL average interaction was not ( = .280). The significant Age EAL high is shown in Figure 4-1. As shown in this figure, the behavioral stress scores of
56 the women with lower educational attainment levels decreased significantly as the age of these women increased, whereas the behavioral stress scores of the women with higher educational attainment levels increased as the age of these women increased. The multiple regression model w ith Cognitive Stress scores as the criterion variable was also significant, adjusted R2 = .091, F [3, 54] = 2.893, p < .05. In this model, age was found to be the only statistically significant predictor of Cognitive Stress scores. Specifically, Cognitive Stress scores as age increased. The interaction te rms did not add a significant amount of variance explained in Cognitive Stress scores, R2 = .010, F [2, 52] = .308, p = .736. The multiple regression model with Nutrition Behaviors scores was significant, and only Age and EAL were significant predictors in this model, adjusted R2 = .160, F [3, 54] = 4.626, p < .01. Specifically, Nutrition Behaviors increased with in creased age and with increase EAL.
57 Table 4-1 Descriptive statistics for the major variables of interest and social desirability Note a Johnson, 2005, b Lefebvre & Sandford, 1985, cThe lowest to the highest score for the identified variable are 1 = St rongly Disagree to 4 = Strongly Agree. Higher scores indicate higher self-reported leve ls of cultural sensitivity in relation to the identified variable. Variable Name Min Max Mean SD Norm Mean Nutrition Behaviors 1.22 3.33 2.38 0.50 2.47a Social Desirability 0.20 1.00 0.70 0.17 N/A Physical Stress 28.00 110.00 63.98 17.44 50.03 b Behavioral Stress 8.00 41.00 23.99 7.33 22.44 b Cognitive Stress 6.00 35.00 14.73 7.39 13.84 b Provider Behaviors/Attitudesc 2.00 4.00 3.33 0.54 N/A Office Staff Behaviors/Attitudesc 1.87 4.00 3.20 0.55 N/A Health Care Center Environmentc 2.14 4.00 3.14 0.48 N/A
58 Table 4-2 Intercorrelations between and among the majo r variables of interest and social desirability Variable 1 2 3 4 5 6 7 8 1. Social Desirability 1.00 2. Nutrition Behaviors 0.16 1.00 3. Physical Stress -0.01 -0.03 1.00 4. Behavioral Stress -0.15 -0.31(**) 0.53(**) 1.00 5. Cognitive Stress -0.16 -0.37(**) 0.48(**) 0.63(**) 1.00 6. Provider Behaviors/Attitudes 0.16 0.16 -0.09 -0.19 -0.21 1.00 7. Health Care Center Environment 0.16 0.09 0.09 -0.09 -0.15 0.78(**) 1.00 8. Office Staff Beha viors/Attitudes 0.15 0.07 0.03 -0.14 -0.12 0.78(**) 0.84(**) 1.00 *p <.05, two-tailed. ** p < .01, two-tailed.
59 Table 4-3 Summary of the multiple regression analysis for the stress variables predicting nutrition behaviors R2 F df B SE B Model 0.22 6.68** 3, 73 Physical Stress 0.01 0.00 0.28* Behavioral Stress -0.02 0.01 -0.31* Cognitive Stress -0.02 0.01 -0.31* *p <.05, two-tailed. **p < .01, two-tailed. Table 4-4 Summary of the multiple regression analysis for the pa tient-centered cultural sensitivity in health care variables pr edicting nutrition behaviors R2 F df B SE B Model 0.03 0.88 3, 75 Provider Behaviors/Attitudes 0.24 0.18 0.26 Office Staff Behaviors/Attitudes -0.19 0.20 -0.21 Health Care Center Environment and Policies 0.06 0.24 0.06
60 Table 4 Hierarchical multiple regression models with behavioral stress, cognitive stress, and nutrition behaviors as criterio n variables and age, educationa l attainment level (average and high), and their interaction terms as predictors Measure Variable R2 F Df B SE B t Behavioral Stress Constant .154 3.575 2, 52 27.2342.111 Age x EAL average .275.183.2801.506 Age x EAL high .497.186.5012.670** Cognitive Stress Constant .138 2.893 3, 54 17.2102.067 Age -.186.078-.317-2.391* Nutrition Behaviors Constant .204 4.626 3, 54 2.177.131 Age .014.005.3712.911** EAL average .184.108.40.2066 EAL high .449.172.4272.607** Note The full models included age, EAL average, EAL high, and all two-way interaction va riables as predictors EAL = educational attainment level. Coding of the predicto rs: Age = age 51.33; EAL average: low or hi gh educational attainme nt level = 0, avera ge education = 1; EAL high: high educati onal attainment level = 1, low or aver age educational attainment level = 0. *p < .05, two-tailed. ** p < .01, two-tailed.
61 Age 9080 70 60 50 40302010Behavioral Stress40 30 20 10 0 EAL EAL high EAL average EAL low Figure 4-1 Age Educational Attainment Level (EAL) predicting behavioral stress CHAPTER 5 DISCUSSION The purpose of the present study was to exam ine both self-reporte d levels of stress (physical s tress, cognitive stress, and behavioral stress) and patient-centered cultural sensitivity in health care experienced (provider behavior s/attitudes, office staff behaviors/attitudes, and health care center characteristics and policies) as predictors of nutrition behaviors among mostly low-income African American women patients dia gnosed with or at risk for hypertension and/or related health conditions (diabetes, high blood cholesterol, and cor onary heart disease).
62 Additionally, this study examined differences in th ese examined patient va riables in association with age and educational attainment level of the participating women patients. This chapter presents a summary and interpretations of the findings in this study, the limitations of this study, the clinical implications of this study and the fu ture research implications from the findings of this study. Summary and Interpretations of the Findings The results of the present study provided par tial support for Hypothesis 1, which stated that am ong low-income African American women patient s diagnosed with or at risk for hypertension and/or related health conditions (diabetes, high blood cholesterol, and coronary heart disease), self-reported levels of stress (physical stress, be havioral stress, and cognitive stress) will have a significant negative association with self-reported level of nutrition behaviors. Physical stress, behavioral stress and cognitive stress were f ound to be significant predictors of nutrition behaviors among low-income African American wo men patients in the present study. However, whereas negative significant associations were found between both self -reported levels of behavioral stress and cognitive stress as stated in Hypothesis 1, a significa nt positive association was found between self-reported level of physical stress and level of nutri tion behaviors, which is contrary to Hypothesis 1. The above findings suggest that psychological stressors may impede health promoting nutrition behaviors among African American women patients such as those in the present study, thus possibly increasing the risk for hypertensi on and related health conditions among these women. These findings are consistent with those of Young, He, Genkinger, Sapun, Mabry,and Jehn (2003) who found that higher perceived stre ss was significantly associated with lower levels of health status and well-being am ong African American women. Additionally, these results are consistent with earlier studies that found a negative association between stress and
63 specific health behaviors (Artinian et al., 2006; George, Milani, Hanss-Nuss & Freeland-Graves, 2005; Griffin, Friend, Eitel & Lobel, 1993; Lukoschek, 2002; Walcott-McQuigg, 1995). The surprising finding that physical stress was positively associated with health promoting nutrition behaviors among the African American women patients in the present study. This finding is inconsistent with the findings of othe r studies which have i ndicated that increased symptoms of stress (tense muscles, racing he art, headaches, nausea or upset stomach) are associated with a decrease in the engagement in health promoting nutriti on behaviors (Chester, Himburg, & Weatherspoon, 2006; George, Milani Hanss-Nuss, & Freeland-Graves, 2005). One explanation for the found positive association be tween physical stress and health promoting behaviors in the present study could be that comp ared to cognitive stress and behavioral stress, physical stress may cause greater visceral reacti ons that elicit actions to alleviate these symptoms. Such preventative actions may include exercising and other stress reducing activities. The finding that self-reported cognitive, beha vioral, and physical stress predicted health promoting nutrition behaviors in th e present study may have impli cation for the Patient-Centered Culturally Sensitive Health Care Model as propo sed by Tucker et al. (i n press). Specifically, perhaps the PC-CSHC Model shoul d be extended to include cogni tive, behavioral, and physical stress as predictors of health promoting be haviors such as nutrition behaviors among African American women diagnosed with or at risk for hypertension and related health conditions. The results of the present study did not suppor t Hypothesis 2 which stated that among lowincome African American women patients diagnosed with or at risk for hypertension and/or related health conditions (diabetes, high blood ch olesterol, and coronary heart disease), selfreported levels of patient-centered cultural sensi tivity in the health care experienced (provider behaviors/attitudes, office staff behaviors/attitudes, and health care center characteristics and
64 policies) will have a significant positive asso ciation with self-reported level of nutrition behaviors. Provider behaviors/attitudes, office sta ff behaviors/attitudes, and health care center characteristics and policies that indicate patie nt-centered cultural sensitivity in the care experienced did not explain a significant amount of the variance in levels of nutrition behaviors among the low-income African American women pa tients in the presen t study. This finding does not provide support for the PC-CSHC Model which proposes that patients perceived levels of patient-centered cultural sensitivity in health care experienced is associated with health promoting behaviors, which in clude nutrition behaviors. The failure of the present findings to support Hypothesis 2 may indicate that self-reported levels of patient-centered cultural sensitivity in health care experienced among low-income African American women patients diagnosed with or at risk for hypertension and/or related health conditions (diabetes, high blood cholesterol, and coronary heart disease) is neutralized by the deleterious effects of socio-environmental influences such as poverty and discrimination on such patients level of nutrition behaviors. Alte rnatively, it may be that the findings of high levels of self-reported cultural sensitivity in the provider behavior/att itudes, the office staff behaviors/attitudes, and in the health care cent er characteristics and policies did not allow enough variance in these variable le vels to reliably determine thei r associations with levels of health promoting behaviors. Indeed, the standard deviations for provi der behavior/attitudes, office staff behaviors/attitudes, and health care center characteristics and policies were only .54, .55, and .48, respectively. The following research question was also examined in the present study: Are there significant age and educational atta inment level differences in se lf-reported levels of stress (physical stress, behavioral stre ss, and cognitive stress), leve ls of patient-centered cultural
65 sensitivity in the health care experienced (provider behaviors/attitudes, office staff behaviors/attitudes, and health care center charact eristics and policies), and level of nutrition behaviors among low-income African American wo men patients diagnosed with or at risk for hypertension and/or related health conditions (d iabetes, high blood cholesterol, and coronary heart disease)? Results form the examination of this resear ch question concluded that the behavioral stress scores of the women with lower educational attainment levels decreased significantly as age increased, whereas the behavioral stress sc ores of the women with higher educational attainment levels increased significantly as age in crease. This finding is consistent with previous research studies that found differences in stre ss levels among low-income women in different age groups and among low-income women with differe nt educational attainme nt levels (Becker, Israel, Schulz, Parker & Klem, 2005; Martin, Gr unendahl & Martin, 2001). This finding may suggest that age buffers against the deleterious effects of stress a nd act as a protective factor for women with low educational attainment in the present study. It is possible that older African American women with lower family incomes when compared to their younger women peers have created more community and family resource s that help protect against behavioral stress (e.g., irritability, smoking, use of recreational drugs, use of alcohol). African American women who attain educational attainment levels may instead experience higher stress with increasing age because of increasing occupational and financia l responsibilities that may come with age and associated career advancement. Specificall y, as these women obtain higher employment positions and earn more money as an outcome of high educational attainment, they may experience more stressors and engage in poorer coping skills, which are components of behavioral stress (e.g., irritability, smoking, use of prescription drugs).
66 Results from the examination of the research question set forth in this study also revealed that age was a significant positive predictor of cognitive stress among the African American women patients in the present study. Cognitive stress addresses more of the psychological components of stress in which feelings of cont rol and empowerment are negatively affected. The positive association between cognitive stress and age found in the present study is inconsistent with the finding of Becker et al. (2005) who found that younger African American women reported increased perceptions of control in the face of high levels of stress when compared to older women. Finally, results from the examination of th e research question set forth in this study revealed that both educational attainment level and age were both significa nt positive predictors of the Nutrition Behaviors scores. These results are consistent with the findings from several studies in the literature that state younger African American adu lts and those who reported lower education levels consume le ss healthy foods (Deshmukh-Task ar, Nicklas, Yang, & Berenson, 2007; Fallon, Wilcox, & Laken, 2006; Jen, Brogan, Washington, Flack, & Artinian, 2007; Shea, Melnik, Stein, Zansky, Maylahn, & Basch, 1993). It is indeed possible that younger African American women patients and less educated Afri can American women patients spend less time in food preparation and are deterred from th e high cost of eating healthy (Jen, Brogan, Washington, Flack, & Artinian, 2007). Limitations of the Present Study Several lim itations suggest caution in interpre ting and applying the re sults of the present study. One of these limitations has to do with two of the instruments used in this study. Specifically, the Strain Questionnaire and the Nutrition Behavior Subscale of the Health Promoting Lifestyle Profile may not have been ideal for use with the low-income African American women in the present study. Specificall y, the Strain Questionnaire measures types of
67 stress that may not adequately represent the t ypes of stress experienced by low-income African American women. Stress as a result of poverty, racism, and discrimination as experienced by African American women such as those in th e present study was not assessed by the Strain Questionnaire. The Nutrition Subscale of the Health Promoti ng Lifestyle Profile may also not have been ideal for measuring level of health promoting nutrition behaviors of th e low-income African American women in the present study. This subs cale assessed level of engagement in selfinitiated health promoting nutrition behaviors that serve to maintain or enhance ones level of wellness, self-actualization, and fulfillment. Such nutrition behaviors may not adequately represent the cultural food preferences (e.g., soul food) or body image attitudes embraced by low-income African American women. Another limitation of the pres ent study is the us e of self-report measures which raise questions regarding the reliability of the obt ained data. Self-report measures of nutrition behaviors may particularly encourage socia lly desirable responses (Johnson, 2005). It is noteworthy, however, that no si gnificant correlations were found between scores on the Marlowe-Crowne Social Desirabili ty Scale and scores on the Nutr ition Subscale of the Health Promoting Lifestyle Profile and scores on the ot her self-report measures in the present study. Yet, these findings do not indicate with certainty that the women patients in this study were not responding without bias. Other limitations in the present study incl ude its small sample size, which may have limited the power of the applied statistical anal yses to find the hypothesized associations among the investigated variables. The small sample also limits the generalizability of the findings in this study. Lastly, the cross sectional design of the present study did not allow for observation of the
68 variables of interest over time. Self-reported levels of patientcentered cultural sensitivity in health care experienced, stress (physical, behavi oral and cognitive stress) and nutrition behaviors can develop and fluctuate as conditions of ones social environment change. Clinical Implications and Future Directions The low nutrition behaviors scores found am ong the low-income African American women in this study further validate the need for interventions to pr omote nutrition behaviors among similar women, particularly those who ar e young. The found negative associations in this study between the participating African American women patients levels of nutrition behaviors and their levels of cognitive and behavioral stress suggest that assessment of stress among African American women patients with or at risk for hypertension and related health conditions need to be part of health assessment of these pa tients. Furthermore, if the findings in the present study are supported in future similar research, support will be provided for assessment-based interventions to reduce cognitive and behavioral stress in efforts to increase levels of nutrition behaviors among African Amer ican women similar to t hose in the present study. Counseling psychologists are particularly well trained to conduct such assessments and interventions. Additionally, stre ss management training in health care settings have been advocated and reported by others (Batey, Kaufmann, Raczynski et al., 2000; Jones, Howe & Brantley, 2001; Linden, Lenz, & Con, 2001; Stephan Auerbach, 1989; Webb, Beckstead, Meininger, & Robinson, 2006). Knowledge of w ithin racial group fact ors (e.g., educational attainment level, age, and stress) in the nutr ition behaviors of African American women with hypertension and other related chronic health cond itions that were identified in the present study is likely important for planning such stress management tr aining (Patt, Yanek, Moy, & Becker, 2004).
69 Future research similar to the present study is implicated. However, such research should include larger samples and meas ures of stress and nutrition beha viors that have been normed on African American patients, especially those sim ilar to the women in th e present study. Future research similar to the presen t study also needs to include mo re diverse samples of African American women patients who attend a wide variet y of health care centers. This diversity will allow more variance among the levels of self-report ed cultural sensi tivity in the he alth care they experience. Additionally, such diversity in perceived cultural sensitivity will enable a more reliable test of the association between perceive d cultural sensitivity in health care experienced and nutrition behaviors than was possible with the high levels of perceived cultural sensitivity in health care experience that exited among the African American women in the present study. Conclusion The present study prim arily examined psychos ocial factors (patie nt-centered cultural sensitivity health care ex perienced and cognitive, behavioral, and physical stress) that influence the level of engagement in health promoting nutrition behaviors among low-income African American women patients diagnosed with or at risk for hypertension and/or related health conditions (diabetes, high blood cholesterol and co ronary heart disease). Overall, findings from this study suggest that levels of stress experienced by low-in come African American women predict their engagement in health promoting nutrition behaviors. Specifically, self-reported levels of physical stress, behavioral stress, a nd cognitive stress significantly predicted selfreported level of nutrition behaviors for the women patients in the pr esent study. Behavioral stress and cognitive stress were positively associ ated with levels of these behaviors whereas physical stress was negatively associ ated with these behaviors. Resu lts also revealed that levels of behavioral stress among the African Americ an women in the present study with lower educational attainment significan tly decreased as age increased, whereas levels of behavioral
70 stress among the African American women in the present study with higher educational attainment significantly increased as age in creased. Finally, it wa s found among these women that age was a positive predictor of cognitive stress level, and that both age and educational attainment level were positive predictors of level of nutrition behaviors. Together the findings and the limitations of the present study may guide future similar research to examine stress and perceived cultural sensitivity in health care experienced as factors in levels of nutrition behaviors among low-income African American women with or at risk for hypertension and related health conditions. This fu ture similar research needs to be culturally appropriate. Specifically the assessments used sh ould be culturally sensitive and diverse African American women who receive health care at various health care centers should be included as research participants. Such research may further elucidate the role of different types of stress in the occurrence of nutritional behavi ors of African American women patients such as those in the present study and may support the growing calls for culturally sens itive health car e and for stress management interventions as a part of health care treatment for this group.
71 APPENDIX A DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ) Please prov ide the requested information by shading in your answer. It should look like this: 1. What is your gender? Male Female 2. Your Race/Ethnicity: Cuban/Cuban-American Dominican Republican Mexican/Mexican-American/Chicano(a) Puerto Rican Other Hispanic/Latino (please specify: _____________________) Caucasian/White/European-American African-American/Black-American Other (please specify: _____________________) 3. Current relationship status: Single, living without a partner Single, living with a partner Married, living with a partner Married, not living with a partner Divorced or separated Widow/Widower 4. Employment Status: Work Full Time Work Part Time Do not work 5. Highest level of educati on that you have completed : Elementary School Middle/Junior High School High School Some College/Technical School College Professional/Graduate School 6. Annual household income level: Below $10,000 $10,001 to $20,000 $20,001 to $30,000 $30,001 to $40,000 Above $40,001 7. Do you have children? Yes (How many?:________) No 8. If so, do your children live with you?
72 Yes No 9. Religious Preference: Catholic Baptist Presbyterian Methodist Islamic Buddhist Jewish Other (Please specify: _________) 10. Language Preference (for future mailings): English Spanish Other (Please specify: ________________________) 11. Which clinic do you attend? Family Practice Medical Group Eastside Community Health care center Other (Please specify: ________________________) 12. Have you changed clinics since beginning this research study? Yes No 13. Have you changed doctors since beginning this re search study? Yes No 14. What other research studies are you involved with at your clinic? (check all that apply) Florida Healthy State Program Medicaid Study Other (pl ease list): _________________________________________ 15. Has there been a change in your primary car e physician or nurse practitioner since you last completed these surveys? Yes No If Yes, please explain: ____________________________________________ 16. Did you receive any help when filling out these surveys? Yes No 17. How many times have you visited your clinic since last completing these surveys? ________ 18. How many years have you lived in this community? __________ 19. What is your Age? __________
73 APPENDIX B MEDICAL DATA QUESTIONNAIRE (MDS) Directions: For this set of ques tions, please fill in the blank or sh ade in the circle nex t to the appropriate response from the c hoices given. Remember, your answ ers to all questions in this packet are kept strictly conf idential and private. Questions ONE through SEVEN are only about hypertension, if you do not have hypert ension, please do not answer these. 1. If you have high blood pressure how many years has it been sin ce your health care provider told you (Circle one)? 0-1 years 2-3 years 4-5 years 6-7 years 8-9 years 10 plus years 2. Have you experienced symptoms related to the high blood pressure (Circle one)? YES NO 3. If you have experienced symp toms, please list them here: 4. Which of the following has your physician or other health care provider recommended to treat your high blood pressure (Check all that apply)? Medication Diet Exercise Weight Loss Other: ____________________________________________________ 5. Have any other members of your family been diagnosed with high blood pressure? YES NO 6. If other members of your family have high bl ood pressure, what re lation are they to you (check all that apply): Mother Son Father Daughter Grandmother Aunt Grandfather Uncle 7. How much do you agree or di sagree that you can get ample amounts of education and consultation about hypertension (Circle your answer)? Strongly Agree Somewhat Agree Neutra l Somewhat Disagree Strongly Disagree 8. What illnesses are you currently diagnos ed with? (check all that apply)
74 Diabetes (Low Blood Sugar) High cholesterol (Hyperlipidemia) High blood pressure (Hype rtension) Coronary Artery Disease Other (please list): ________________________________________ 9. How long ago were you told that you had the conditions listed above? ILLNESS OR CONCERN YEARS _________________________________________________________________ ____________________ _____________________________________________ ____________________ _____________________________________________ ____________________ _____________________________________________ 10. Are you currently on any medications? YES If Yes, please list them: ___________________________ NO 11. Has your physician recommended you to exercise, di et, or take medications for any of these other illnesses or medical concerns? If so, please list: YES NO
75 APPENDIX C HEALTH PROMOTING LIFESTYLE PROFILE II (HPLP-II) This questionnaire contains statem ents about you r present way of life or personal habits. Please respond to each item as accurate ly as possible and try not to skip any item. Indicate the frequency with which you engage in each beha vior by filling in the appropriate circle. Never Sometimes Often Routinely 1. Discuss my problems and con cerns with people close to m 2. Choose a diet low in fat, saturated fat, and cholesterol. 3. Report any unusual signs or symptoms to a physician or other health professional. 4. Follow a planned exercise program. 5. Get enough sleep. 6. Feel I am growing and changing in positive ways. 7. Praise other people easily for their achievements. 8. Limit use of sugars and food containing sugar (sweets). 9. Read or watch TV programs about improving health. 10. Exercise vigorously for 20 or more minutes at least three times a week (such as brisk walking, bicycling, aerobic dancing, using a stair climber). 11. Take some time for relaxation each day. 12. Believe that my life has purpose. 13. Discuss my problems and c oncerns with people close to me. 14. Choose a diet low in fat, saturated fat, and cholesterol. 15. Report any unusual signs or symptoms to a physician or other health professional. 16. Follow a planned exercise program. 17. Get enough sleep. 18. Feel I am growing and changing in positive ways. 19. Praise other people easily for their achievements. 20. Limit use of sugars and food containing sugar (sweets). 21. Read or watch TV programs about improving health. 22. Exercise vigorously for 20 or more minutes at least three times a week (such as brisk walking, bicycling, aerobic dancing, using a stair climber).
76 23. Take some time for relaxation each day. 24. Believe that my life has purpose. 25. Maintain meaningful and fulf illing relationships with others. 26. Eat 6-11 servings of bread, cereal, rice, and pasta each day. 27. Question health professionals in order to understand their directions. 28. Take part in light to modera te physical activity (such as sustained walking 30-40 minut es five or more times a week). 29. Accept those things in my life which I cannot change. 30. Look forward to the future. 31. Eat only 2-3 servings from the meat, poultry, fish, dried beans, eggs, and nuts group each day. 32. Ask for information from health professionals about how to take good care of myself. 33. Check my pulse rate when exercising. 34. Practice relaxation or medita tion for 15-20 minutes daily. 35. Am aware of what is important in my life. 36. Get support from a network of caring people. 37. Read labels to identify nutrients fats, and sodium content in packaged food. 38. Attend educational programs on personal health care. 39. Reach my target heart rate when exercising. 40. Pace myself to prevent tiredness. 41. Feel connected with some force greater than myself. 42. Settle conflicts with others through discussion and compromise. 43. Eat breakfast. 44. Seek guidance or counseling when necessary. 45. Expose myself to new experiences and challenges. 46. Spend time with close friends. 47. Eat 2-4 servings of fruit a day. 48. Get a second opinion when I question my health care providers advice. 49. Take part in leisure-time (re creational) physical activities (such as swimming, dancing, bicycling). 50. Concentrate on pleasant thoughts at bedtime. 51. Feel content and at peace with myself. 52. Find it easy to show concern, love, and warmth to others. 53. Eat 3-5 servings of vegetable each day.
77 54. Discuss my health concerns with health professionals.
78 APPENDIX D MARLOW-CROWNE SOCIAL DESI RABILI TY SCALE (MCSDS) Directions: For each of the following statements please fill in where you consider the statement to be True (T) or False (F). True False 1. I never hesitate to go out of my way to help someone in trouble. 2. I have never intensely disliked anyone. 3. I sometimes feel resentful when I dont get my way. 4. I like to gossip at times. 5. There have been times when I felt like rebelling against people in authority even though I knew they were right. 6. I can remember playing sick to get out of something. 7. There have been occasions when I took advantage of someone. 8. Im always willing to admit it when I make a mistake. 9. I always try to prac tice what I preach. 10. I sometimes try to get even, rather than forgive and forget. 11. When I dont know something I dont at all mind admitting it. 12. I am always courteous, even to people who are disagreeable. 13. At times I have really insi sted on having things my way. 14. There have been occas ions when I felt like smashing things. 15. I would never think of letting some one else be punished for my wrongdoings. 16. I never resent being asked to return a favor. 17. I have never been irked when people expressed ideas very different from my own. 18. There have been times when I was quite jealous of the good fortune of others. 19. I am sometimes irritated by people who ask favors of me. 20. I have never deliberately said some thing to hurt someones feelings.
79 APPENDIX E STRAIN QUESTIONNAIRE (SQ) Please read the following list and fill in the bubble of the letter that most closely corresponds to how often in the past week you have experienced or felt each of the items listed. A=Not at All B=Rarely C=Sometimes D=Frequently E=Everyday (0 days) (1-2 days) (3-4 days) (5-6 days) (7 days) A B C D E 1. Backaches 2. Muscle soreness 3. Numbness or tingling in body 4. Heaviness in arms or legs 5. Weakness in body parts 6. Tense muscles 7. Pain in neck 8. Nausea or upset stomach 9. Diarrhea or indigestion 10. Tight stom ach 11. Loss of or excessive appetite 12. Pain in heart or chest 13. Shortness of breath 14. Racing heart 15. Light headedness 16. Headaches 17. Hot or cold spells 18. Lum p in throat 19. Dryness of throat and mouth 20. Teeth grinding 21. Trembling or nervous tics 22. Sweating 23. Sweaty hands 24. Itching 25. Cold or warm hands 26. Frequent need to urinate 27. Spent m ore time alone 28. Irritability
80 29. Impulsive behavior 30. Easily startled 31. Stuttering/ other speech dysfluencies 32. Insomnia 33. Inability to sit still 34. Smoking 35. Use of prescription drugs 36. Use of alcohol 37. Accident proneness 38. Believe the world is against you 39. Feeling out of control 40. Urge to cry or run away 41. Feeling of unreality 42. Feeling that you are no good 43. Inability to c oncentrate 44. Nightmares 45. Think things cant get any worse 46. Faintness o r dizziness 47. Used recreational drugs 48. Premenstrual tension or missed cycles
81 APPENDIX F TUCKER CULTURALLY SENSITIVE HEALTH C ARE INVENTORY-AFRICAN AMERICAN PATIENT FORM (T-CUSCHI-AA) DIRECTIONS : Take a few seconds to think about your experi ences with the person you see most often for health care at your health care c linic. This person might be a doctor, a nurse practitioner, or some other health care provider. Now please rate how much you agree that this person shows each characteristic or behavior listed below when pr oviding you with health care. Please use a rating of 4, 3, 2, or 1 where 4 = Strongly Agree, 3 = Agree, 2 = Disagree, and 1 = Strongly Disagree. Shade in the circle below the rating you choose like this Please rate all characteristics and behaviors listed on each page. Do not give us your name. Your ratings will be confidential Thus, please give honest ratings. Strongly Agree Agree Disagree Strongly Disagree 4 3 2 1 THE PERSON I SEE MOST OF TEN FOR MY HEALTH CARE WHEN I VISIT MY CLINIC: 1. Is compassionate or shows that he or she cares about how I feel. 2. Is honest and direct with me. 3. Is dedicated to her or his work. 4. Has a lot of schooling. 5. Knows what he or she is doing. 6. Responds to my requests. 7. Appears to be concerned about my well-being.* 8. Treats all of her or his patients equally. 9. Makes helpful and reasonable recommendations. 10. Explains things so that I understand them 11. Shows that he or she is trying to help me out. 12. Treats me like a person, not just a number.* 13. Shows that he or she is inte rested in more than just making money. 14. Follows a common procedure for treating all of his or her patients. 15. Shows that he or she is familiar with my health. 16. Consults with others to help me. 17. Is not scared to touch me.
82 18. Takes my concerns seriously.* 19. Tries to communicate with me. 20. Talks to me during my visit. 21. Does not look down on me.* 22. Prescribes medicine only when he or she is sure of my illness. 23. Correctly diagnoses and treats my illness. 24. Is available for me. 25. Is consistent in her or his diagnosis and treatment of my illness. 26. Prescribes medicine only when he or she is sure of my illness. 27. Explains things so that I can understand them 28. Listens to me. 29. Takes her or his time with me during my visit. 30. Lets me explain my symptoms before examining me. 31. Examines me carefully before making any decisions. 32. Refers me to a specialist when he or she cannot help me. 33. Explains everything he or she does to me. 34. Knows her or his limits as to what she or he can treat. 35. Does not make me wait long. 36. Puts on a fresh pair of gloves while I am in the examining room. 37. Follows up on m y visits. 38. Talks to me before making decisions about prescriptions and treatments. 39. Has a positive attitude. 40. Keeps up with new research and treatments. 41. Treats me with respect.* 42. Puts my mind at ease. 43. Is polite.* 44. Gives me the information that I need. 45. Is sensitive to my needs. 46. Treats all of her or hi s patients the same way. 47. Speaks English well enough for me to understand what he or she is saying. 48. Lets me know about illnesses and diseases common among African Americans.
83 49. Prepares me for the next steps in treating my illness. 50. Shows that he or she remembers me.* 51. Looks professional. 52. Understands my fina ncial situation.* 53. Comforts me.* 54. Makes me feel appreciated. 55. Shows care and concern for my ch ild. [If no children, please do not rate this.] 56. Tries to help me out. 57. Creates positive feeli ngs during my visit. 58. Chats with me during my visit. 59. Is nice.* 60. Is respectful of my religious beliefs.* 61. Knows how to make me feel comfortable.* 62. Understands the African American culture.* 63. Has training in working with African American patients. Now please rate how much you agree that overall the staff members at your clinic show each of the following characteristics and behavior s. To do this, use the same scale as above and choose one of the four ratings for each characteristic and behavior, then shade in the circle below the rating you choose like this Please rate all of the listed characteristics and behaviors. Strongly Agree Agree Disagree Strongly Disagree 4 3 2 1 THE CLINIC STAFF MEM BERS AT MY CLINIC: 1. Are friendly.* 2. Are helpful.* 3. Are polite.* 4. Are professional. 5. Are skilled at working with people. 6. Are welcoming. 7. Give me a card to remind me of my next appointment. 8. Call me the day before my appointment to confirm it. 9. Get back with me as promised.
84 10. Appear concerned about my well-being. 11. Treat me with respect. 12. Do not make unprofessional comments. 13. Treat me like a person, not a number. 14. Make fair decisions about who the doctor is going to see next. 15. Do not discriminate against me because of my race.* 16. Do not look down on me.* 17. Do not stereotype African Americ an patients as unable to read and uneducated. 18. Allow me to reschedule a missed appointment within a reasonable time. 19. Keep my business confidential and private. 20. Do not gossip about patients. 21. Do not grab my children from me [If no children, please do not rate this.] 22. Do what the doctor told them to do for me. 23. Work with my case even if I cannot pay the doctors bills. 24. Pay attention to me.* 25. Listen to my complaints.* 26. Know my name.* 27. Admit me quickly after my initia l registration or sign-in as a patient. 28. Take care of me as soon as I walk in. 29. Get the doctor to see me at the time of my appointment. 30. Work quickly to process my paperwork before and after I s ee the doctor. 31. Let me know if there are any changes to my record. 32. Give more work effort to seeing patients in the clinic than to answering phone calls. 33. Allow me to discipline my children while I am inside the clinic. [If no children, please do not rate this.] Now please rate how much you agree that the following clinic characteristics exist at your health care clinic. To do this, us e the same scale as above and choose one of the four ratings for each clinic characteristic, then shade in the circle below the rating you choose like this Please rate all of the liste d the clinic characteristics.
85 Strongly A g ree Agree Disagree Strongly Disagree MY HEALTH CARE CLINIC: 4 3 2 1 1. Is a clean place. 2. Is a comfortable place. 3. Does not smell. 4. Is professional looking like a clinic should be. 5. Has affordable services. 6. Has doctors and nurses visibly moving about treating patients. 7. Has short waiting times to see the doctors. 8. Has procedures to make sure that I am seen by the doctor at the 9. Is a calm place. 10. Is open late for patient s who work during the day. 11. Has fresh air. 12. Has brochures available about i llnesses or diseases common to 13. Has signs and posters about illnesses and procedures on the walls. 14. Has a hotline I can call for illness information. 15. Has a sign-in sheet. 16. Has large and spacious or roomy waiting rooms. 17. Has warm waiting rooms. 18. Has waiting rooms that are not crowded. 19. Has many chairs in the waiting room. 20. Has comfortable chairs in the waiting room. 21. Has many convenient places to park your car or other vehicle. 22. Has warm examining rooms. 23. Has many receptionists and staff members working. 24. Has African American doctors working at the clinic. 25. Has African American staff working at the clinic. 26. Has the same doctors all the time. 27. Makes sure that I am treated with in 15 minutes of my appointment. 28. Makes sure that neither patient s nor staff are allowed to gossip. 29. Has a social worker at the clin ic available to help me with insurance and disability problems.
86 APPENDIX G STUDY PARTICIPATION INVITATION LETTER Dear Patie nt: You have an opportunity to participate in a University of Florida research study about your experiences as a patient at the Family Practice Medical Group. WHAT IS THIS ABOUT? The researcher wants to know about your ex periences with your doctors, nurses, and clinic staff. The information you give us is very important because it may help us improve the health care and support that you and other pa tients like you receive from healthcare providers. WHAT DO YOU HAVE TO DO? If you agree to participate, we will ma il Study Questionnaires to you. Depending on when you join the study and/or when you stop participation, you will be asked to complete between two and six assessment packets approximately once every four to six months. You may also participate in a short traini ng session near the end of the study. HOW LONG IS IT GOING TO TAKE? Completing the Study Questi onnaires should take no more than one hour each. WILL MY ANSWERS BE KEPT PRIVATE? Yes! Nobody will know if you agree to participate. Nobody at the Family Practice Medical Group will see your answers if you complete the questionnaires. WILL I BE PAID? Yes, you will be paid twenty dollars ($20 ) each time you complete and return the Study Questionnaires that we will send you. Y ou will also receive sixty dollars ($60) if you decide to come to the traini ng session near th e end of the study. HOW CAN I FIND MORE ABOUT THIS? Please read the Informed Consent Form (i n English or Spanish) that was mailed with this letter, or call the Principal Researcher (D r. Carolyn Tucker) at (352) 392 0601, ext. 260. WHAT SHOULD I DO IN CASE I DECIDE TO PARTICIPATE? 1. Sign the last page of both Inf ormed Consent Forms (English or Spanish). Keep one copy for yourself. 2. Complete the Demographic Data Form. 3. Complete the Medical Data Form. 4. Return one copy of the Informed Consent Form, the Demographic Data Form and the Medical Data Form in the pr e-addressed, postage paid envelope. DO NOT add postage, just seal the enve lope and put it in your mailbox. WHAT SHOULD I DO IF I MOVE?
87 If you move after you return the Informed Consent Form and before you receive more information from us, simply call (352) 392-0601, ext. 260 between 10:00 a.m. and 4:00 p.m. Feel free to call collect if necessary. WHO CAN ANSWER SOME MORE QUESTIONS I HAVE? If you have any questions about this resear ch, contact the Principal Researcher, Dr. Carolyn M. Tucker, at (352) 392-0601, ext. 260. Thank you for your time. We hope you will consider participating in this study. Sincerely, Dr. Karen L. Hall Medical Director, Family Practice Medical Group
88 APPENDIX H INFORMED CONSENT FORM IRB# 289-2002 Informed Consent to Par ticipate in Research and Authorization for Collection, Use, and Disclosure of Protected Health Information Patient Form PLEASE SIGN BOTH COPIES OF THIS FORM AND RETURN ONE TO THE RESEARCHERS You are being asked to take part in a research study. This form provides you with information about the study and seeks your authorization fo r the collection, use and disclosure of your protected health information necessary for the st udy. The Principal Inves tigator (the person in charge of this research) or a representative of the Principal Investigator will also describe this study to you and answer all of your questions. Your participation is entire ly voluntary. Before you decide whether or not to take part, read the information below and ask questions about anything you do not understand. If you choose not to participate in this study you will not be penalized or lose any benefits that you would otherwise be entitled to. 1. Name of Participant ("Study Subject") ________________________________________________________________________ 2. Title of Research Study A Patient-Centered Culturally Sensitive Care Model 3. Principal Investigator and Telephone Number(s) Carolyn M. Tucker, Ph.D. Distinguished Alumni Professor Professor of Psychology, Director of Training Professor of Pediatrics Professor of Community Health and Family Medicine (352) 392-0601 extension 260 4. Source of Funding or Other Material Support This research is being funded by the Agency for Healthcare Quality and Research (AHRQ) of the National Institutes of Health (NIH). 5. What is the purpose of this research study?
89 Sometimes people are not completely happy or satis fied with some behavi ors of their health care providers or with something about their hea lth care clinic. Such dissatisfaction may be more likely in patients who are culturally or racially different from their health care providers. This can be a problem because be ing unhappy with ones health care provider can get in the way of a sick person getting better. In this st udy, we want to do two things: (1) find out whether making health care more culturally sensitive through a training program and some changes in the health care clinic will make patients more satisfied with their health care and reduce their stress, and (2 ) teach patients how to better communicate with health care providers so that the health care experience will be as satisfactory as possible. 6. What will be done if you take part in this research study? This study has seven parts; Parts A-G. If you choose and are selected to participate, you will be invited to participate in five parts of the study. Below is a description of what participation in each part of this study involves. Parts A Part B Parts A and B of this study are already completed. These parts involved recruitment of patients to fill out an initial set of surveys. Parts C Part F -If you participate in these four parts of the study, you will be asked each time to fill out a set of surveys, with approxim ately 4 months between each of the parts. Specifically, one survey will ask how much you ag ree or disagree with statements describing certain behaviors of your health care providers that may or may not be culturally sensitive. Other surveys will ask about your lifestyle, you r relations with health care providers, your stress levels, and your involvement in various health behaviors. You will also be asked to complete a survey about yourself which asks about your age, gende r/sex, race, years of having any long-term health problems, a ny communication problems you may have, how you pay for your health care, your telephone number, your address, your current clinic, and the number of visits that you have made to your current clinic in the past year. Filling out all of these surveys will take about one hour. You may choose to do these four surveys in one of two ways. The first way is to fill out the surveys at home and mail us the filled out surveys in a pre-paid reply envelope provided with the packet. The second way is to fill out the surveys at the clinic that you atte nd. One of our research assistants will be at the clinic to help you fill out the surveys if you need any help or have any questions. Your name will not be used on the surveys. Inst ead, researchers will place a code number on the surveys that you fill out. Your surveys will be immediately separated from any documents that may be able to identify you (like your signed informed consent form) and locked in separate filing cabinets in room 293 at the De partment of Psychology at the University of Florida. Your health care provider will not see your filled out surveys and will not be told whether you are participati ng in the study or not. Part G -If you participate in this part of the st udy, you will be asked to participate in a 4hour patient training on strategies for asking for and receiving more culturally sensitive and more desired health care. You are not required to participate in this part of the research in order to participate in the prev ious four parts. The patient training will i nvolve you along with a small group of other patients. During the training session, you will hear a brief talk
90 by the trainer, watch videos on how to talk w ith your doctor and other clinic staff members, and watch or participate in some demonstrations of how to ta lk with ease to health care providers and other clinic staff. Although you are i nvited to participate in all sections of this training, you do not have to pa rticipate in each activity and may stop whenever you choose or when you feel uncomfortable. You will be paid for your participation in each pa rt. The amount that is paid for participation in the first four parts is the sa me. Participants in the fifth part of the study will be paid differently than in the first parts. To see how much money is paid for participation in each part, see section 10 of this form 7. What are the possible discomforts and risks? Some of the questions that you wi ll be asked on the surveys could make you feel uncomfortable. If you do feel
91 APPENDIX I STUDY QUESTIONNAIRE PACKET COVER LETTER Dear Patient: Thank you for your sustained interest in our re search project. W e are a Research Team, supervised by Dr. Carolyn M. Tucker, Distinguished Alumni Professor at the University of Florida. The purpose of this pr oject is to determine ways to increase the level of cultural sensitivity in health care provided to patients. The other purpose of this project is to see if patients benefit from more culturally sensitive health care. Participation in this study involves completi ng a set of questionnaires. One of these questionnaires includes a list of be haviors of health care provider s and clinic personnel and a list of clinic characteristics that pa tients have told us indicate sens itivity to their culture. Although we do not believe that your completing this questionnaire or the other questionnaires will cause you any harm, you do have the right to skip any questions that you find offensive and you have the right to stop completing a questionna ire if it makes you feel uncomfortable. You will be asked to complete these same questi onnaires again in approximately five months. If you choose to complete the questionnaires again, you will again receive compensation for your time. You may decide later whether or not you would like to complete the questionnaires again. Your participation in this res earch project is voluntary. If you experience any discomforts with completing these questionnaires, you may call Dr Carolyn M. Tucker, at (352) 392-0601 ext. 260, and/or the University of Florida Institut ional Review Board (IRB) Office at (352) 846-1494 to discuss your concerns. Your information will not be shared with your doctor or othe r members of the health care staff at your clinic. Also, your name will not be placed on any of the questionnaires that you complete. Instead, the information from you will be assigned a code number. The list of names that identify these codes will be kept in a separate locked location from the information that you provide us with. The questionn aires that you provide us will be destroyed as soon as all information from you and other participants has b een gathered. All this information will be locked in file cabinets in Dr. Tucker's lab in th e psychology building at the University of Florida. All information from participants will be combin ed so that no one can identify your information. The information you give us is very important b ecause it may help us imp rove the health care and support that you and other patients like you may receive from health care providers. In return for your participation in our study, you will be mailed a payment of $20 within three (3) weeks of when we receive your completed qu estionnaires and payment release form. Please, in addition to completing the questionnai res, sign and return the completed Payment Release Form. We need your name, address, an d social security number requested on this form so that we can send you a check for $20. Your signed Informed Consent Form (which you returned previously) and Payment Release Forms w ill be locked in a separate file cabinet from the locked file cabinet in which your completed que stionnaires will be kept. This will be done to further protect your confidentiality.
92 In order to participate, please complete the enclosed questionnaires and Payment Release Form, then return them by mail in the pre-paid reply envelope provided This should only take about an hour. If you need help comp leting the questionnaires, you may ask a family member or friend to read them to you; howev er, we only want your opi nions to the questions You may also call Dr. Carolyn M. Tucker at (352) 392-0601, Ext. 260 to set up an appointment to have a Research Assistant read the questionnaires to you at th e health care clinic that you attend. If you have any questions about this research proj ect, please call a member of our research team at the (352) 392-0601 ext. 260. We are l ooking forward to yo ur participation. Sincerely, Dr. Carolyn M. Tucker Distinguished Alumni Professor Professor of Psychology Professor of Pediatrics Professor of Community Health and Family Medicine
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102 BIOGRAPHICAL SKETCH Jessica Dorothy Jones is a gr aduate student in the Univer sity of Floridas C ounseling Psychology Doctoral Program and a graduate director on the Patient -Centered Culturally Sensitive Health Care Project. She received her undergraduate degree from the University of Florida in 2003 with a Bachelor s of Science in Psychology. She is also a student member and founder of the Diversity Awareness and Affirma tion Committee and a student member on the Student Travel and Research (S.T.A.R.) Fund Committee. Currently her research interests are in culturally sensitive health care, multicu ltural counseling, and social advocacy